Background
The burden of undernutrition remains unacceptably high with 800 million people globally and 780 million of these residing in low-to-middle income countries, especially in Sub-Saharan Africa and South Asia [
1]. Children under the age of five years are highly vulnerable, as 150.8 million children are stunted and 50.5 million are wasted [
2]. Apart from other factors, inadequate food intake and poor dietary quality are responsible directly or indirectly for causing ill-health with six of the top eleven global risk factors being associated with dietary imbalances [
1] and in 2017, 11 million deaths and 255 million disability-adjusted life years (DALYs) were attributable to dietary risk factors [
3].
The Provision of packaged specialised food supplements are argued to be a rapid and low cost approach to prevent under-nutrition in vulnerable groups such as pregnant-lactating women (PLW) and young children 6–59 months of age [
4,
5] and more specifically focusing on the critical 1000 day period from conception to 2 years of age [
6,
7]. These specialized packaged foods comprise of various products which are carefully designed to cater the needs of specific vulnerable groups. Fortified Blended Foods (FBFs) are designed for PLW and consist of a blend of partially precooked cereals in either wheat or corn base and fortified with vitamins and minerals which is mixed with water and cooked [
8]. Ready to Use Foods (RUF) are designed for children 6–59 months of age and are eaten in small quantities as a supplement to regular diet and are prepared in a lipid base providing proteins, fats and micronutrients [
9,
10]. Micronutrient powders (MNP) are single use powder packets of vitamins and minerals which is sprinkled on cooked meals of children [
11]. High energy biscuits comprising of proteins and minerals have also been designed for children and adults especially in emergency settings. These food supplements are usually provided for the prevention of stunting through community-based approaches to ensure access to the most marginalized with appropriate counselling and support [
12].
Food supplementation programs for the prevention of stunting have been implemented as part of food security measures in many countries including India, Malawi, Bangladesh, Madagascar and Ghana [
13‐
16]. The existing evidence of the impact of FBF and RUFs to prevent stunting remains inconclusive [
4,
11,
14,
17,
18]. Moreover, most of the available evidence is from trials, where there is stringent monitoring for food distribution and greater support to mothers [
14,
15,
18,
19]. However, in large scale health programs, the distribution and effective uptake of food supplements is certain to be more challenging especially if the food is to be taken regularly over a longer period of time.
There is an increasing body of evidence for the impact of ready-to-use therapeutic foods (RUTFs) for under-nutrition, but relatively less evidence on the effect of food supplements for the prevention of stunting. Mixed method studies have also been conducted to explore the adherence and acceptability of food supplements within the community and to understand the contextual factors associated with appropriate consumption [
20]. The available evidence on the factors influencing the usage of food supplementation is presently small and emerging, and there is a greater need for evidence emerging from real programmatic settings and outside of controlled trial settings as these could provide real insights on how community adherence can be improved.
We present here the findings from a process evaluation of a pilot study on food supplement based stunting prevention program conducted in two rural underserved districts of Sindh province in Pakistan. This paper focuses on the process evaluation, while a separate paper would be published on the effectiveness of the intervention. We used a mixed methods approach to delve into community dynamics around the usage of food supplements to prevent stunting, hence contributing to the empirical insights for effective community uptake of food supplements when designing food supplementation programs in food insecure settings. This study was conducted in Pakistan 40.2% children are stunted, the highest in South Asia and nearly twice as much as the global prevalence [
21].
Method
Setting
The is a process evaluation of a two-year stunting prevention project (2014–2016), where food supplements were provided to PLW and children 6–59 months of age in two districts (Thatta and Sujawal) of Pakistan with an established high prevalence of childhood stunting. The food Supplements were provided in the 29 Union Councils (UCs) -the lowest administrative unit- of the total of 55 UCs of the two districts through community-based Lady Health Workers (LHWs). The food supplements consisted of locally produced LNS (Wawamum – chocolate drink) given to children from 6 to 23 months of age, MNPs (powder to be sprinkled on food) to children 24–59 months of age and Wheat Soy Blend (WSB) (chickpea based fortified food to be mixed with flour) to PLW during pregnancy and for 6 months after giving birth (Table
1). Besides the provision of food supplements, counselling was provided on food supplement use and infant and young child feeding (IYCF) (early initiation and exclusive breastfeeding, sustained breastfeeding, complementary feeding and hygiene practices). The details of the program and methodology are provided elsewhere [
22].
Table 1
Food Supplements and targeted beneficiaries
LNS (Wawa Mum) | Children aged 6–23 months | 1 sachet (50 g) Once a day | Directly from the sachet |
MNP | Children aged 24–59 months | 1 sachet Every other day | Sprinkled over semi-solid or solid food |
WSB | Pregnant and/or lactating women | 5 kg (2 bags) Spread throughout the month | Making bread or desserts |
The LHW program has been running for several years in Pakistan and operates through salaried village-based lady health workers who provide frontline maternal and childcare preventive services growth monitoring, and identify severe disease and ensure timely referrals. Each LHW has a health house in her village as the centre point for health awareness sessions, and also conducts home visits on a monthly basis. The LHWs are supervised by Lady Health Supervisors (LHS) based at a health facility where they also collect commodities and submit monthly reports.
Food intervention
In this program, all the PLW and children < 5 years of age residing in the 29 LHW covered UCs were the beneficiaries of the food supplementation program irrespective of their nutritional status. Food stocks (LNS for children aged 6–23 months, MNP for children aged 24–59 months and WSB for PLW) were collected by LHWs during their monthly visit to the health centre and mothers then visited the LHW health house in their respective villages to receive the monthly supplements. The mothers were provided information on food supplement use and further follow-up on food usage were done by LHWs during routine household visits.
Process evaluation
In this study, we investigated the community dynamics related to the uptake of ready to use food supplements by the intended recipients through a cross-sectional mixed methods assessment. This study was based on the five key parameters critical to the success of a food supplementation program which were identified through a review of the existing literature and comprised of
We used a range of mixed methods to explore the above parameters (Table
2):
i)
Household quantitative survey of PLW and mothers of children under 5 years of age- to examine receipt of food supplies, knowledge and consumption.
ii)
Focused group discussions (FGDs) with female and male caregivers probing value, acceptability, receipt of supplies, consumption by targeted beneficiaries
iii)
FGDs with LHWs probing community uptake and delivery factors affecting usage
iv)
Key informant interviews (KIIs) with district stakeholders probing community uptake and delivery factors affecting usage
Table 2
The data collection tools and parameters
Community level dynamics affecting uptake of food supplements by targeted beneficiaries | -Are food supplements being received by households? -Does the community understand the value and purpose of supplements? -Is there acceptability of food supplements amongst target groups and particular likes and dislikes associated with different supplements? Is there consumption by required beneficiaries and in sufficient quantities | HH Survey (n = 806) | Mothers | -Receipt of food supplements -Usage of food supplements by target groups -Knowledge of food supplement usage |
Community perceptions FGDs (n = 18) | PLW: 2 FGD Fathers & male HH members of < 5 children: 6 FGDs | -Value of food supplements and willingness to pay -Acceptability of food supplements - Receipt of food supplements -Usage of food supplements |
Health provider feedback FGDs (n = 4) KIIs (n = 22) | FGDs: LHWs KIs: district and union council stakeholders | Enablers & Barriers related to: -Uptake of food supplements by community -Delivery of food supplements |
Data collection
Household survey
A structured paper-based questionnaire was used to collect data from randomly identified households (HH). Sample size was calculated using the comparison of sequential surveys approach to detect a 15% difference in ever receiving food supplements by eligible population. Sample size calculations considered the percentage of food supplement received during the previous process assessment i.e. 69% and design effect of two and the total sample size calculated was 806 to detect a 15% difference with 80% power and 5% level of significance. No minors (16>) were included in the sample. The HH survey was conducted in 12 UCs randomly selected from both districts and the probability proportional to size (PPS) sampling method was used to randomly select houses from the lists of HH already available with the LHWs (Additional file
1).
FGDs with caregivers
We randomly selected 12 UCs from the targeted 29 UCs to conduct FGDs. A total of 18 FGDs were conducted with community members: twelve FGDs were conducted with mothers and mothers-in-law, and six with male members of households. Each FGD had 8–10 participants, and lasted around 2 h. A topic guide with probes was used to gather information on value, distribution, acceptability, and usage of food supplements during these discussions (Additional file
2).
FGDs with LHWs
A total of 4 FGDs were conducted with LHWs which were randomly selected from 12 UCs. Each FGD had 8–10 participants and lasted around 2 h. A topic guide with probes was used to probe LHW perceptions on community uptake of supplements, underlying factors and LHW experiences on delivery of food supplements (Additional file
2
).
KIs with district stakeholders
A total of 22 KIIs were carried out with district stakeholders, including the district health office staff, union council representatives, community-based organizations, and Lady Health Supervisors (LHS) overseeing LHWs. A topic guide was used to probe perceptions on community uptake of supplements, factors underlying community uptake and perceptions of programmatic delivery of food supplements (Additional file
3)
.
Quality assurance
Two field-based teams were formed; one for household survey and the other for qualitative investigation and each was headed by a field supervisor. The study lead and research specialist trained both the team on study tools, oversaw data collection and real time analysis. Household questionnaire was pre-tested before data collection, validation checks were done on 5% of the forms within the same day and errors corrected. Data forms after being checked for completeness by field supervisor were entered into SPSS using double entry to minimise errors.
FGDs with community members were conducted in an accessible location, usually in a village home or school chosen by the participants. Space at local government health facilities was used for FGDs with LHWs as it is a common convening point. Each FGD was conducted by a pair of facilitators and note taker, held in local Sindhi language, and principles of free flow of conversation were established at the outset. Tape recorders were used with permission of the participants. FGDs and KII were conducted in local language, transcription was carried out during field data collection, and after checking with the audio recordings were translated to English.
Data analysis
Quantitative data was analyzed in Stata version 14. We performed descriptive analysis and frequencies were generated for all of the categorical variables. The transcripts from FGDs and KIIs were manually analyzed using inductive thematic analysis and content coded a priori in line with the identified five parameters. Coding was reviewed by the study team, discrepancies were discussed, relationship between themes was discussed and new codes created where felt necessary. Triangulation of emerging findings was done across HH survey, community FGDs, LHW FGDs and KIs to identify commonalities and differences.
Ethical considerations
The project obtained ethical approval from the Ethics Review Committee (ERC) of Aga Khan University (GN: 2919-Ped-ERC-14) and the National Bioethics Committee (NBC) (4–87/14/NBC-147/RDC/624) of the Pakistan Medical and Research Council. Written informed consent was obtained from survey participants prior to collection of data. The FGDs and KIs began with introduction of the study, re-confirmation of interest to participate in the discussion, and maintained confidentiality of respondents’ information. Identifying information of respondents was removed in transcription, analysis and reporting, substituting with numeric codes. All computerised data was encrypted, and hard copies were stored in locked cabinets to ensure confidentiality of data.
Discussion
There is an increasing interest in the use of food supplements for the prevention of childhood stunting, however the evidence only from strictly monitored trials remains incomplete, hence meriting the exploration of contextual process indicators. This study contributes to the much needed evidence on the perceptions of the community and the most peripheral health workers and this evidence can entail the factors which would need the most emphasis, so that the large scale food supplementation programs can be successful in reducing childhood stunting.
The findings from this study (Table
5) show that the consumption of full dosage of supplements by intended target groups was sup-optimal for all the three supplements, despite reasonable knowledge amongst care-givers. The quantitative findings also suggest issues with the supply chain, from the supply to the health facilities, lady health workers and to the pickup by the community. WSB was well accepted as an extra ration and LNS was popular due its chocolate taste and texture, whereas MNP sprinkles were perceived to be of little value as they were disliked by children and linked with diarrhea. Sharing was also common amongst the other household members, especially for WSB and LNS. The community largely did not perceive stunting as a problem but considered it due to God’s will and due to the family heredity. While community members were willing to utilise food supplements if provided free of cost there was little WTP for the supplements.
Table 5
Summary of key findings
HH Survey |
| -Supplement not available -majority of mothers were aware of delivery points | -LHW absent at health house | | | -Target groups did not receive adequate amounts |
Community Perceptions: FGDs with Family Members |
-Stunting not viewed as a problem- seen as genetic and God’s will/natural Mothers could see improvement in child’s growth post-supplements | -Information on usage not provided to family members who collected supplements | -Correct usage technique only taught to mothers by LHWs LHWs hurried the sharing of information | -WSB- taste and texture liked by PLW; seen as source of energy and provided physical strength -LNS- children liked chocolatey taste -MNP- changed the colour of food and taste, so was not liked by target population (or otherwise). | -Lack of trust regarding government intervention -Village elders volunteered to play a positive and productive role in promotion and encourage use of food supplements in their community | - LNS and WSB were shared by household members |
Healthcare Provider Feedback: FGDs with LHWs |
| -Supplements not restocked due to transport allowance issues -Male members of the households that come to collect supplements do not wish to stay and learn about usage technique or dosage. | -LHWs felt overwhelmed by multiple tasks -Expressed need for support by LHSs | -Need for village level committee to supervise education and distribution of supplements by elders and educated community members | Demotivating factors affecting usage: -lack of time, supplies, oversight, skills, trainings and support by LHSs | -Concerned regarding target groups not receiving adequate amounts due to sharing of supplements |
District Stakeholders Feedback: KIIs |
-Benefits of supplements to alleviate stunting not understood | -Transport allowance is not regularly provided for restocking and transport of supplements | -LHSs stated that LHWs need more education and training on community awareness Poor record keeping by LHWs | | -LHWs focused more on anti-polio drives and family planning Multiple commitments make it difficult to effectively run supplement program | |
The major issue for the effective utilisation of the intervention was the lack of communication between the community and the LHWs and the major barriers from the LHW side were lack of support and time for these additional activities. There was poor awareness in the community as well as shortfalls in the food supplementation delivery process. The LHWs didn’t have sufficient time due to keeping records and other tasks, were not adequately trained for BCC and were not supervised adequately. There was reluctance from CHWs and field supervisors to absorb food supplementation into their regular routine of work unless supported by extra work stipends, and even then it was felt to overstretch their capacity to deliver. Reliance on CHWs to transport heavy supplies was considered problematic as transportation expense were not timely disbursed. KIIs from district stakeholders also felt the need for more concerted community awareness as well as wider sharing of food monitoring information with public stakeholders. To strengthen the behavior change communication, and to ensure correct information dissemination and consistent monitoring, multiple stakeholders should be mobilized including the LHS,, community midwives (CMWs) and village elders.
The trials conducted in Ghana, Haiti, Peru, Bangladesh and Malawi show wide acceptability of food supplements [
13‐
15,
25,
26]. However, evidence from Ghana and Malawi found low WTP for food supplements in households indicating continued subsidization in provision of food supplements [
27]. The sharing of supplements with other household members has been reported in at least two other studies, and highlights cultural imperatives to feed all family members and motherly instinct to share food among all her children that can hinder deliberative targeting of food supplements [
13,
14]. Other studies have also found that the distance of the collection point, delay in funds and supplement distribution affect the delivery and use of the supplements [
28‐
30]. There is little evidence on community health workers and their role in supporting food supplement usage, with some evidence indicating inadequate capability of the community workers detrimentally impacting food supplements usage [
29,
31].
The strength of our study is that firstly it is not confined to a controlled trial environment in investigation of community uptake of food supplements. Secondly it explores different parameters of uptake drawn from available literature including value, acceptability, receipt of food, usage and targeting compliance. Third, it applies a diverse range of quantitative and qualitative methods to explore food uptake and also distills findings across the levels of community, health workers and district supervisors. Finally, it inductively picks up issues related to community health worker delivery as part of village-based food supplement distribution, an area that has been extensively explored in existing body of literature and provides powerful compelling reasons that need to be acted on to improve food uptake. One of the limitations of this study was not designed to determine diets of children and hence at least the quantitative findings are limited to supplements received and used in the last month, however the qualitative investigation draws on accumulative experience over time. Our study is a descriptive study and does not attempt to test a specific hypothesis and assign quantitative scores. Another limitation was not collecting data on number of children < 5 years in the household, compliance of food supplement and sharing with siblings for all children within household.
Our study shows that blanket food supplementation in communities for certain high-risk groups (children, PLW) is not likely to be seen as targeted to these individuals. Even when there is awareness, the moral obligation and reluctance to refuse results in sharing with other family members.
Conclusion
We conclude that provision of food supplements to vulnerable populations must be rolled out with caution, with careful attention to village-based dynamics in designing an effective program. Community acceptability of food supplements does not translate into optimal consumption, instead a greater emphasis is needed on demand creation amongst caregivers, countering food sharing practices, implementing efficient logistical mechanisms and moving from sole reliance on community health workers to a broadening of food delivery and behavioural change alternatives. Our study underscores the challenges for community health workers given these additional tasks and a need for additional support with supervision, and finding ways to enhance motivation with incentives. The food supplementation programs in the similar contexts need to meticulously plan and cater to the challenges with context specific planning focused towards improved worker motivation, efficient delivery channels, enhanced communication and involvement of multiple stakeholders. There is a need for similar studies in varying contexts around various low- and middle- income countries which would help form universal guidelines.
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