Perspectives on acceptability, feasibility and equity of nutritional supplementation interventions.
The findings related to nutritional supplementation for the prevention of wasting, as well as the availability of information related to coverage, are summarised in the summary table of findings presented in Table 3.
Infant and child supplementation: Complementary foods
Theme 1.1: Alternative foods are mostly perceived to be good for infant and young child, but acceptability is affected by familiarity (indirect evidence): Caregivers felt that IYC had improved health, physical and cognitive development when provided with alternative foods that are familiar to them. As a result of this experience, caregivers perceived these interventions to be effective. Some caregivers, however, felt that some foods, such as eggs, can be harmful for IYC. Alternative foods that beneficiaries were unfamiliar with were less acceptable as children often refused them, and caregivers preferred the formula milks they knew.
Theme 1.2: Caregivers not understanding the rationale for providing alternative foods as well as discomfort about receiving support may act as barriers to uptake, but this can be counteracted by motivation from healthcare workers (indirect evidence): Perspectives from caregivers suggested that many were unwilling to accept that their child is moderately wasted, with one caregiver stating that the child is ‘just naturally small’. In cases where caregivers did acknowledge their child’s condition, many attributed this to witchcraft and consequently could not see how the foods would remedy the situation. These misconceptions presented as barriers to uptake, as many of these caregivers refused to provide the alternative foods to their children. Caregivers expressed a preference for alternative foods they are familiar with, such as age-specific, commercially available milks that are highly marketed. They also reported feeling ashamed and stigmatised by the provision of alternative foods at home, as they felt that social perception would be that they have a sick child or are unable to care for their children. However, second-order constructs indicated that caregivers found fetching alternative foods from health centres burdensome and objected to this. These factors may present as barriers to implementation. It was highlighted in second-order constructs by researchers that healthcare workers (HCWs) who understand the barriers to effecting behavioural change can play an important role as facilitators by motivating and stimulating the participation of caregivers.
Theme 2.1: Small-quantity lipid-based nutrient supplement is mostly considered to be good for child well-being and convenient, and children enjoy them (direct and indirect evidence): Caregivers felt that the nutritional supplements improved the appetite, vitality, health, activity, physical and cognitive development of their children. They also did not experience feeding children with SQ-LNS to be inconvenient and found preparation easy. Most caregivers reported that children enjoy the taste of SQ-LNS; some children disliked it initially, but they grew to enjoy it.
Theme 2.2: Caregivers do not always have control over providing small-quantity lipid-based nutrient supplement for infant and young child in the way that it is intended (indirect evidence): Some caregivers reported practices that may cause target children not to receive SQ-LNS as intended, potentially causing a barrier to effective implementation. In some cases, SQ-LNS was shared because other children in the household also enjoyed the taste, with other caregivers reporting that they locked the supplement away so other household members could not access it. Not all caregivers gave SQ-LNS alongside other complementary food as instructed because of a lack of resources. In addition, certain caregivers raised concerns about providing the SQ-LNS in a hygienic manner because of poor or non-existent sanitation facilities and a lack of clean water.
Theme 3.1: Ready-to-use supplementary food is mostly considered to be good for child well-being and convenient, and children enjoy it (direct and indirect evidence): There was high acceptability for RUSF among caregivers as they experienced it as convenient and relieving the financial burden on the household. Caregivers felt that the nutritional supplements improved the appetite, vitality, health, activity, physical and cognitive development of their children. Some caregivers believed that the RUSF is medicine and Western food of higher effectiveness than those found locally; however, the uncertainty around its provenance caused distrust of the product for some. Because of its perceived effectiveness and the perception of RUSF being medicine, most caregivers did not share it with other members of the household, although some did indicate that they gave small quantities to other children. Some breastfeeding mothers also reported consuming some of the RUSF intended for their children as they believed it guaranteed their milk supply. Most caregivers reported that children enjoy the taste of RUSF; some children disliked it initially, but they grew to enjoy it. Many caregivers reported that they mixed RUSF with other foods initially so children would eat it.
Theme 3.2: Information and education may facilitate ready-to-use supplementary fooduse, while social factors and poor sanitation may be barriers to implementation (direct and indirect evidence): The need for information and education sessions as facilitators to implementation was highlighted, with researchers noting the impact of these on the consumption of the product. There was an interaction of gender roles, social position and socio-economic status with the intervention, with child feeding seen as ‘women’s business’. Some caregivers reported that proper sanitation or water was not available to handle RUSF in a hygienic manner in some cases.
Theme 3.3: Caregivers do not always have control over providing ready-to-use supplementary food for infant and young child in the intended amount because of sharing practices (direct and indirect evidence): Caregivers indicated that they understand that sharing RUSF is counterproductive and that the whole ration is needed for the intended child. However, caregivers reported that some reasons out of their control resulted in RUSF being shared: these included gender (fathers and husbands instructing caregivers to give supplements to other children), seniority in the household (senior co-wives demanding RUSF for themselves or their children), social capital (sharing RUSF with neighbours with the understanding that this would be reciprocated in a time of need), as well as older children taking rations when caregivers are not at home.
Theme 4.1: Fortified blended foods are thought to be good for children and are considered medicines by some, but sensory attributes and burden of preparation may affect acceptability (direct and indirect evidence): Caregivers felt that the nutritional supplements improved the appetite, vitality, health, activity, physical and cognitive development of their children. Some caregivers reported that grandmothers suggested to them that they should have their child enrolled in the programme providing FBF because of concern that the child’s weight is low. Caregivers also experienced FBF as relieving the financial burden on the household and appreciated the reduction in medical costs because of their children’s improved health. Some caregivers believed that the FBFs are medicine and Western food. Perspectives suggest that these caregivers believe that FBFs are local foods that have been ‘transformed’ into foods of higher effectiveness. Because of its perceived effectiveness and the perception of FBF being medicine, most caregivers did not share the FBF with other members of the household, although some did indicate that they gave small quantities to other children. In addition, breastfeeding mothers also consumed some of the FBF intended for their children as they believed it increased their milk production. While caregivers found preparation easy, they experienced it as a burden on their time in cases where their children rejected the FBF. Caregivers reported that children enjoy the taste of FBF; some children disliked it initially, but they grew to accept it. However, most children did not like the smell of the CSB as it reportedly smells strongly like medicine. Caregivers reported that not all children enjoy the taste, with caregivers reporting that the FBF is too sweet for their children. Furthermore, caregivers reported that the colour and texture of the porridge changed after some time and found this unappealing. Many caregivers reported that they served FBF raw or ‘moistened’, as they would when preparing local couscous, based on the child’s preference and sometimes contrary to the instructions for preparation.
Theme 4.2: Education may facilitate fortified blended foods use, while social factors, taste and quality, as well as limited sanitation, may be barriers to implementation (direct and indirect evidence): The need for information and education sessions as facilitators to implementation was highlighted, with researchers noting the impact of these on the consumption of the supplement. Some barriers to effective and safe implementation were also identified. Gender roles, social position and socio-economic status interacted with the intervention and affected implementation, with child feeding seen as ‘women’s business’. Caregivers reported that proper sanitation or water was not available to handle FBF in a hygienic manner in some cases. Some caregivers also reported that FBF did not taste good as it was bitter and old; this was attributed to the flour being old and spoilt when they received it. Caregivers themselves reported that they did not always have the proper sealed containers to keep FBF fresh and pest-free.
Theme 4.3: Caregivers do not always have control over providing fortified blended food to intended infant and young child only (direct and indirect evidence): Caregivers indicated that they understand that sharing FBF is counterproductive and that the whole ration is needed for the intended child. However, caregivers reported that some reasons out of their control resulted in FBF being shared: these included culture within the household (co-wives demanding FBF for themselves or their children) and social capital (sharing FBF with neighbours with the understanding that this would be reciprocated in a time of need), as well as older children taking rations when caregivers are not at home.
Theme 5.1: If adequately informed, caregivers mostly consider child micronutrient supplementation to benefit child well-being and be convenient (direct and indirect evidence): Caregivers experienced that the MNS improved the health, appetite, energy as well as physical and cognitive development of their children. In addition, it was perceived by caregivers that MNS helps to prevent anaemia in children, thereby reducing the need for ‘expensive foods’. Although some caregivers did report negative gastrointestinal side effects, this was considered to be a sign that the intervention is working. These experiences were key to the acceptability of MNS as education alone would not have resulted in such a high level of acceptability. Caregivers found that the appearance of MNS makes it easy to give to children, as the white colour made children think it is sugar; the colour also makes it easy to blend into rice. However, some caregivers reported that they were not sure how to mix the MNS with food, and that they did not know what the MNS was, while some caregivers indicated distrust of the intervention and its rationale.
Theme 5.2: Misconceptions of intervention providers and poor communication hinders implementation of child micronutrient supplementation (direct and indirect evidence): Most intervention providers felt that MNS distribution increased their workload. However, the acceptable taste and ease of administration of MNS, as well as the benefits to children, made this an acceptable intervention from the perspective of most intervention providers, and as a result most did not mind the additional burden. However, some intervention providers from a study reporting indirect evidence did not seem to understand the intervention themselves: misconceptions around the types of foods that MNS should be mixed into as well as a lack of willingness to use educational materials may be barriers to implementation from the intervention providers’ side. Caregivers’ responses about the types of foods that MNS can be mixed into echo the misconceptions of intervention providers. Caregivers expressed a need for more frequent MNS distribution as this would mean more contact with intervention providers ‘of whom they would be able to ask questions if they had any problems’. In the study where intervention providers indicated low levels of intervention coherence, caregivers indicated higher levels of distrust in MNS. This uncertainty around preparation and rationale, as well as reported gastrointestinal side effects of the product, may be barriers to implementation from the caregivers’ side.
Theme 6.1: Perspectives on the tolerability and health benefits of alternative food for mothers were mixed (direct evidence): Pregnant women had mixed feelings about the sensory attributes of the alternative food. There was general acceptance for the texture and taste, but the smell was less acceptable. There were mixed feelings about the health benefits of the alternative food for mothers and babies. Women indicated that they would use the alternative food daily during pregnancy as the main belief was that it was good for the baby only.
Theme 7.1: Acceptability of and adherence to small-quantity lipid-based nutrient supplement for mothers was affected by sensory experiences, perceptions on side effects and beliefs about health benefit (direct evidence): Pregnant and lactating women (PLW) had mixed feelings about SQ-LNS, with some experiencing the taste and smell as unpleasant, while others reported that it tastes good. Some women also perceived that SQ-LNS causes side effects during pregnancy, including vomiting. These experiences and perceptions affected adherence. Intervention providers agreed with the perspectives of PLW around the challenging taste and smell of SQ-LNS; this perceived acceptability may have impacted on feasibility. Even though some women did not enjoy the SQ-LNS, they reported that they continued using it, as they believed the nutrients in it to be beneficial to their own health and strength as well as the health and intelligence of their unborn babies. However, some mothers reported that, after the birth of their child, they consumed less SQ-LNS, or did not have time to eat it, as they perceived that it does not provide the same benefits to their child post-partum.
Theme 7.2: Mothers do not always trust unfamiliar or foreign small-quantity lipid-based nutrient supplement food products, which impacts adherence (direct and indirect evidence): Foreign SQ-LNS, provided in packaging with a language that was not understood by PLW, was treated with scepticism and curiosity. This resulted in some women destroying the product, while some women shared the product with other pregnant or lactating women. Intervention providers reported that some PLW were not home to receive the product, some did not take it because of monotony or ‘laziness’ to do so, and some avoided it because of adverse effects related to the smell, such as vomiting.
Theme 8.1: Acceptability of ready-to-use supplementary food for mothers was affected by sensory experiences and perceptions on side effects although beliefs about health benefits improved adherence (indirect evidence): Pregnant and lactating women accepted the taste and texture of the RUSF with docosahexaenoic acid (DHA), although some reported not enjoying the taste. Most women reported a strong dislike for the fishy smell. Even though some women did not enjoy the RUSF, they reported that they continued using it, as they believed the nutrients in it to be beneficial to the health and intelligence of their babies. As pregnant women were considered to be more sensitive to certain foods and smells, the RUSF was perceived to be more tolerable after birth.
Theme 9.1: Uptake of maternal micronutrient supplementation is poor because of its taste, side effects, competing priorities and misconceptions around the intervention (indirect evidence): Some PLW experienced iron–folic acid supplements as having a bad taste and causing side effects such as nausea and vomiting. As a result, some did not like to take the supplement, while others stopped taking it entirely. Some perspectives suggested taking the supplements might also be a burden: participants were evenly divided on whether taking the tablet or pill with a meal is difficult; some reported forgetting to take these supplements because of household chores, such as childcare. Those who considered taking the supplement to be easy had mostly already adopted the behaviour. Some perspectives suggested that uptake is affected by a lack of understanding of the intervention. Perspectives of women suggested the discontinuation of supplementation was because of lactating or concerns that the foetus would grow too large and complicating delivery: ‘My mother told me the baby will grow too big and that taking too many tablets is not good for pregnant women’.60
Theme 9.2: A lack of prioritisation of maternal malnutrition affects feasibility of providing maternal micronutrient supplementation (indirect evidence): A lack of understanding and low awareness of the severity and consequences of maternal malnutrition at both the HCW and beneficiary level were identified by intervention providers as serious barriers. These shortcomings resulted in low prioritisation and poor implementation from the intervention provider’s side, as well as poor uptake and a lack of interest from the side of PLW.
Intervention providers further highlighted weak systems in terms of programme management, procurement, logistics and information management, as well as constrained resources such as buildings, staff and equipment, as barriers to reaching vulnerable populations to improve maternal malnutrition.
Theme 9.3: Differential access to maternal micronutrient supplementation caused inequity (indirect evidence): Pregnant and lactating women reported that travelling far from remote areas to healthcare clinics is challenging, with some discontinuing supplementation for this reason. Some also reported that financial constraints, caste and tribal discrimination and the low social standing of women resulted in differential access to services.
Theme 10.1: Community involvement in the production of alternative foods for mothers and children can ensure sustainability (indirect evidence): Intervention providers expressed that buy-in from communities is essential to ensure the sustainability of a programme providing pregnant women and young children with alternative foods. Encouraging the production of local foods for this purpose was identified by intervention providers as an approach, although some experiences indicated that this has to be done sensitively as certain plants may have negative connotations for local communities. For example, health promoters encouraged the cultivation of a local spinach-like plant without realising that it ‘… is considered by the local people to be an aphrodisiac, which leads to a reluctance to openly farm this plant’.52
Theme 10.2: Intra-household food distribution is a cultural practice that affects intervention adherence to alternative food for mothers and children (indirect evidence): Caregivers and pregnant women relayed experiences around the sharing of food among family members. Some noted specifically that cultural issues determine who gets food first, while others reported that poverty often necessitated that wage-earning family members eat first to ensure they can work.
Theme 11.1: PLW may not always tolerate small-quantity lipid-based nutrient supplement, but most children tend to enjoy it (direct evidence): Some PLW experienced the texture, taste and smell of SQ-LNS as unpleasant. Women frequently reported vomiting and nausea resulting from the smell and taste of the SQ-LNS. This was particularly true for pregnant women, and more so for women during early pregnancy, as it was reported that these experiences were diminished post-partum or later in the pregnancy. Some women even reported eating SQ-LNS directly from the sachet as a snack later in the study. Researchers concluded ‘the majority of the nausea and vomiting experienced by the women was because of their physiological state in early pregnancy’.46 However, a small proportion of women continued to experience nausea and vomiting even post-partum. Specific comments relating to sensory dislikes of SQ-LNS suggested that the taste and smell of groundnut were not acceptable to some, while others felt it was too sweet or bitter. Some women reported that they did not mind the sensory attributes of SQ-LNS as long as it is beneficial to their health. Ways of overcoming the negative sensory experiences included mixing SQ-LNS into porridge and adding sugar to it. Despite these, some women would not use SQ-LNS when they did not have the food they liked mixing it into, and most women described incidents of non-adherence. In contrast, caregivers of children reported that they liked the colour and consistency of SQ-LNS. They also experienced that their children did not refuse to eat SQ-LNS and liked the taste and smell of it. However, some caregivers reported that children would enjoy SQ-LNS more if it were sweeter, and one woman suspected that her child did not like the supplement because of the smell. One woman reported that her child had vomiting and diarrhoea after eating SQ-LNS. Most caregivers approved of the consistency of SQ-LNS as it was easy for children to eat and easy to mix into hot rice, although a minority had trouble mixing it with rice.
Theme 11.2: Experiences of self and others influence the uptake of small-quantity lipid-based nutrient supplement for mothers and children (direct evidence): Unrealistic expectations of cause and (immediate) effect, likely because of past experiences, as well as attribution of events, rightly or wrongly, to SQ-LNS also influenced uptake. On the one hand, women expressed concern that taking nutritional supplementation could lead to large babies and obstetrical complications. This was based on beliefs of ‘women in the community’, suggesting that this perception may be anecdotal.53 On the other hand, some women did not see the need for supplementation as ‘children grew normally, whether the mother took supplements or not’,46 indicating an expectation that visible growth should be seen nearly immediately.
Theme 11.3: People interact differently with small-quantity lipid-based nutrient supplement for mothers and children based on whether they believe it to be medicine or not (direct evidence): A theme emerging strongly from the quotes indicated that many beneficiaries believed that SQ-LNS is medicine. Researchers reported that in Ghana, women typically referred to Nkatepa as ‘blood tonic mixed with groundnut paste’, and in Malawi, women said ‘… there is medicine in Chiponde, to increase blood in the body’.46 This perception was reinforced by instructions on SQ-LNS use being given by nurses or doctors at health facilities; many women had memorised the instructions for SQ-LNS correctly and reported that they consumed SQ-LNS according to these instructions. However, researchers reported that several caregivers opined that SQ-LNS should be promoted as ‘special food’ and not ‘medicine’. These contradictory positions seemed to drive the way in which beneficiaries interacted with SQ-LNS. Several PLW had negative sensory experiences of SQ-LNS as they said they could smell or taste the ‘medicine’ in the product or feel the particles of ‘blood tonic’ on their tongue. Some who could not tolerate its organoleptic properties reported going to buy Pregnant Care vitamin and mineral supplement from the hospital. This practice may have been based on another reported perception that SQ-LNS should replace all usual pregnancy medications. Other women compared their experiences of SQ-LNS with earlier pregnancies when they took medicine (such as vitamin B complex); some considered SQ-LNS better, while others preferred pills and tablets. Pregnant and lactating women reported not using SQ-LNS when they had been to the hospital for an injection, stating that they do not take SQ-LNS together with injections. Pregnant and lactating women experienced health improvements and increased energy and felt that they had more breast milk to feed their children. Most caregivers perceived that the SQ-LNS was good for their children through improvements in the health, energy and appetite of the child.
Theme 11.4: Gender roles and cultural sharing practices may result in small-quantity lipid-based nutrient supplement for mothers and children not reaching its intended beneficiaries (direct evidence): Cultural sharing practices were commonplace and reported as being shared with both adult sisters of PLW as well as their children in the matrilineal Malawian society.
Women did not have autonomy in decision-making about taking SQ-LNS or giving it to their children but had to ask their husbands. Beliefs about whether SQ-LNS was medicine influenced whether husbands allowed women to take it. Beneficiary women expressed that all women should receive SQ-LNS, and that poor women should be prioritised – this was in the context of a trial giving SQ-LNS to a random sample of eligible participants.
Theme 12.1: Information about multiple micronutrient powders (MMPs) for mothers and children and its purpose is important for acceptance (indirect evidence): Beneficiaries in the refugee camp expressed a need to understand what micronutrient powder (MMP) is and what it is used for before they would use it. The confusion around its purpose was seen in perspectives attributing reduced aches and pains, easing of childbirth, trouble with sleeping and being hungry to the product. Distrust of the product came through strongly because of a lack of understanding and because it was not delivered by health providers but rather the World Food Programme (WFP). It should be observed that these perspectives come exclusively from a displaced group of respondents. Healthcare providers agreed with beneficiaries that distribution of MMP by the WFP, instead of by healthcare providers, is inappropriate and unacceptable. Insufficient information about MMP disempowered them from dispelling beneficiary distrust, and therefore some gave discouraging information to beneficiaries.
Theme 12.2: A lack of information and cultural/religious sensitivity may exacerbate inequity in the provision of maternal and child micronutrient supplementation (indirect evidence): A lack of information on the ingredients of MMP led people of the Muslim faith to be concerned about the constituent elements and whether these were halal. A participant from Somalia reported that some residents of the refugee camp believed that the MMP was made of meat, adding that haram foods would be discarded. In addition, the packaging depicted a genie- or ghost-like figure that was seen as offensive to people of the Islamic faith and discouraged its use among Muslim people in the camp.