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
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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 SQLNS,
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
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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.