Acceptability and utilization of a lipid-based nutrient supplement formulated for pregnant women in rural Niger: a multi-methods study

Nutrient requirements are increased during pregnancy and essential to meet the needs of both the developing fetus and mother. In resource-poor settings with poor food availability or limited dietary quality, it may be difficult for pregnant women to meet optimal nutrient intake through traditional diets alone [1]. Sub-optimal nutrient intake during pregnancy can contribute to adverse pregnancy outcomes, including increased maternal and neonatal mortality, as well as long-term developmental impairment for the child [2‐4].

Several strategies are recommended to help meet the higher nutritional requirements during pregnancy, including iron folic acid (IFA) and multiple micronutrient (MMN) supplementation [5]. IFA supplementation alone can reduce anemia and iron-deficiency anemia at term, but is associated with adverse effects from high doses of iron and low compliance [6]. MMN supplementation with IFA has been shown to have positive impacts on neonatal health outcomes, including reduced risk of small-for-gestational age, low birthweight, and stillbirth [7].

Recent evidence suggests that combining MMN with both energy and protein may improve birth outcomes compared to MMN or IFA alone [8, 9]. Therefore, a promising new strategy to meet the nutritional needs in pregnancy involves the provision of lipid-based nutrient supplements (LNS). LNS are micronutrient-rich pastes that are often made of peanuts, oil, sugar and milk powder and require no preparation or refrigeration during home use. First developed in large-quantities (92 g) at therapeutic doses for the treatment of severe acute malnutrition, LNS can also be provided in smaller quantities to meet specific nutrient gaps [10]. The first evidence for LNS use among pregnant women in Ghana and Malawi suggest that a small-quantity dosage (20 g) may be acceptable in these populations [11, 12].

The current study builds on this limited experience by reporting on the acceptability and utilization of LNS among pregnant women in rural Niger. We aimed to assess a 40 g LNS formulation with increased micronutrient content before testing effectiveness in terms of maternal and child health outcomes. Despite the larger dose and increased micronutrient content, we hypothesized that the 40 g LNS would be both acceptable and appropriately utilized among pregnant women in Niger given previous experience with LNS among children in this context and general palatability of the new formulation.

Characteristics of participating women are presented in Table 2. Mean (SD) age was 29.5 (7.5) years in June (Ramadan) and 27.9 (7.8) years in September (non-Ramadan), with women reporting a mean of approximately 5 previous pregnancies in both time periods. Very little illness was reported in the 24 h before any test meal, and all participants reported having usual appetites.

Using a two-part, multi-methods design, this study assessed the acceptability and utilization of a new formulation of LNS designed to meet the specific nutrient needs of pregnant women in rural Niger. Findings indicated very high acceptability among the study sample across two time periods. Participants rated Epi-E highly, with positive attitudes toward its organoleptic properties of color, taste, smell as well as an overall liking of the supplement, both immediately following two observed test meals but also after a 14-day home trial. Few side effects were reported, and women expressed an eagerness to continue to use Epi-E and a willingness to pay for it in the future. Acceptability was high in the Ramadan and non- Ramadan study periods, though we observed differing strategies for home utilization during the Ramadan holy month.

LNS has been reported to be highly acceptable for the prevention and treatment of undernutrition in children across various contexts [18, 20‐22, 27‐34]Ethnographic research using qualitative methods [22, 35‐37] and ‘willingness to pay’ studies [38] similarly suggest high acceptability. The high acceptability recorded in this study is most consistent with experience using a 20-g LNS among pregnant and lactating women in Ghana [11]. In this similarly designed study, 64.0% (7/11) of participants gave the 20-g LNS an overall score of 5 (‘Like a lot’) after a 14-day home trial. LNS dose, micronutrient content, as well as social, cultural and economic characteristics of the study settings, however, differed.

Our study provides unique insights into LNS utilization in this population overall, and by time period. We found that participants made decisions about when to eat the supplement on an individual basis, determined by pragmatic household considerations and personal hunger cues that varied importantly by time period. In addition, while all participants were instructed to consume Epi-E as a home fortificant, mixed with local foods, participants preferred consuming Epi-E directly from the sachet. This utilization pattern differs from that found among pregnant women in Ghana, where nearly all participants (91.0%) reported mixing the 20-g LNS with “porridge” (73.0%) and “other foods besides porridge” (e.g., “soups, stews, bread, and other traditional dishes”) [11] and from that found among pregnant and lactating women in Bangladesh, where 83–89% of women mixed the LNS with rice and other foods [39]. It is unclear why such different modes of utilization emerged between settings. However, it may be likely that the mode reported in our study stemmed from participant familiarity with PlumpyNut®, a therapeutic product in the LNS family which is eaten directly from the sachet by malnourished children, and has been used in the Maradi region for over 10 years. It could be attributed to differences in the level of emphasis placed on compliance by study staff in each setting or differences in individual dietary rules or preferences of pregnant women between settings [40, 41]. Consumption direct from the sachet may also be a strategy to limit sharing in a context where food is traditionally shared within the household. When probed, our study participants explained that eating from the sachet just tasted better and was more convenient. Though not prescribed as per study protocol, we observed no adverse implications of this preferred, more convenient mode of utilization.

There are a number of strengths to this study. We first sought to understand acceptability from multiple angles and perspectives, considering the array of indicators to define and assess acceptability. By using both quantitative and qualitative data collection methods on the same topic, our study design included methodological triangulation. By investigating both the attitudes and behaviors of the participants themselves, as well as those reported by the interviewers, we were also able to corroborate findings among different participant types through participant triangulation [26, 42]. The use of repeated observations of test meals on consecutive days reduced the likelihood of reactive behaviors from just a single observation period [43], while repeated observations of the home trial during non-Ramadan and Ramadan time periods provided a more comprehensive understanding of time-dependent dietary behaviors and their potential influence on LNS utilization. These strategies increase our confidence in the positive findings.

This study did have important limitations. First, the home-feeding trial was 14 days long and therefore findings may not reflect long-term acceptability. Ensuring sustained behavior change over time is a particularly difficult aspect of introducing new health practices and may be influenced by household-level utilization factors not assessed in this study [44]. High short-term acceptability observed in this study, however, was accompanied by very few adverse events, suggesting future compliance may be sustainable. High LNS acceptability has recently been shown to be sustained over longer time periods (e.g. up to 12 months) [45], and found to be associated with good adherence during community-based programming [46]. Second, social desirability to provide positive responses may have positively biased participant responses and interviewer field notes [47]. With this in mind, we built in multiple methods to assess LNS acceptability, including the repeated observations, the objective measures of timed and weighed test meals, and the multiple forms of triangulation. Third, the LNS test-meal amount was relatively small (50 g), although if the product were not acceptable based on flavor alone, then it should have been evident even with the small amount provided. Future studies may provide alternative preparations for testing (e.g. alone, mixed with maize meal, mixed with other local foods) to help identify preferences for the mode of utilization relevant for future public health programming. Fourth, the study did not assess participants’ dietary intake or gestational age at enrollment, and did not conduct statistical testing for comparisons other than the primary aim. Finally, these results are context specific, specific to rural Niger where there is high seasonal food insecurity, limited social and economic development [48] and a beneficiary population that has had previous experience with other ready-to-use foods. A relatively smaller sample size was deemed adequate in this specific, homogenous population.

In light of the potential for widespread use of LNS for the prevention and treatment of malnutrition in this setting, future studies are warranted to test and better understand acceptability. Studies among pregnant women with test-meals and home-feeding trials that are conducted over longer time periods, across different seasons, and during special time periods may yield more accurate estimates of acceptability and compliance. Future studies would benefit from data collection at the household-level, where less reactive behaviors may more likely be captured, and from longitudinal follow-up. Such findings are likely to provide a richer perspective of product acceptability and utilization. Larger study samples may also allow researchers to better explore differences in acceptability by participant type.

This study was the first to assess the acceptability and utilization of a 40 g LNS formulation among pregnant women in Niger. Despite its novel formulation designed to meet the nutrient needs of this vulnerable population with a dose nearly two times the typical given in other interventions, and with a higher-than-usual micronutrient profile, acceptability was high. The mode of utilization varied by household and individual considerations, but did not influence overall consumption. The Epi-E formulation will be tested as a potential strategy to improve the adequacy of nutrient intake and birth outcomes among pregnant women in this context.