Understanding malnutrition management through a socioecological lens: Evaluation of a community-based child malnutrition program in rural Uganda
Authors: Gagnon-Dufresne Marie-Catherine , Fortin Geneviève , Bunkeddeko Kirsten , Kalumuna Charles , Zinszer Kate 
Published: September 2021

ABSTRACTIn Uganda, almost half of children under 5 years old suffer from undernutrition. Undernutrition, a common form of malnutrition in children, encompasses stunting, wasting and underweight. Causes of child undernutrition are complex, suggesting that interventions to tackle malnutrition must be multifaceted. In addition, limited access to healthcare for vulnerable populations restricts the potential of hospital-based strategies. Community-based management of acute malnutrition (CMAM), which includes nutritional counselling, ready-to-use therapeutic foods and the outpatient management of malnutrition by caregivers, is recognised as an effective approach for children’s recovery. However, evaluations of CMAM programs are largely based on biomedical and behavioural health models, failing to incorporate structural factors that influence malnutrition management. The objective of this evaluation was to understand the factors influencing malnutrition management in a CMAM program in rural Uganda, using the socioecological model to assess the multilevel determinants of outpatient malnutrition management. This evaluation used qualitative methods to identify determinants related to caregivers, healthcare and societal structures influencing children’s outpatient care. Data were collected at a community health clinic in 2019 through observations and interviews with caregivers of malnourished children. We observed 14 caregiver-provider encounters and interviewed 15 caregivers to examine factors hindering outpatient malnutrition management. Data were thematically analysed informed by the socioecological model. Findings showed that caregivers had a limited understanding of malnutrition. Counselling offered to caregivers was inconsistent and insufficient. Gender inequality and poverty limited caregivers’ access to healthcare and their ability to care for their children. Factors at the caregiver- and healthcare-levels interacted with structural factors to shape malnutrition management. Results suggest that CMAM programs would benefit from providing holistic interventions to tackle the structural barriers to children’s care. Using a socioecological approach to program evaluation could help move beyond individual determinants to address the social dynamics shaping malnutrition management in low- and middle-income countries.WHAT IS KNOWN?CMAM is recognised as a promising strategy to address moderate and severe acute malnutrition in children under five years old in resource-poor settings.Evaluations of CMAM programs largely focus on factors related to caregivers’ choices, behaviours, and practices to explain why CMAM has inconsistent results.Limited attention has been given to the multilevel determinants that influence the outpatient management of malnutrition in CMAM programs.WHAT THIS PAPER ADDS?Caregivers had limited understandings of malnutrition and its underlying mechanisms.Counselling provided to caregivers by program personnel was inconsistent and insufficient, often including contradicting information about treatments prescribed to children.Structural factors limited caregivers’ access to healthcare and their ability to comply with CMAM outpatient protocols.