Facilitators and Barriers to Access and Utilization of a Comprehensive Nutrition Program in Rural Malawi – A Qualitative Study
Authors: Ruel‐Bergeron Julie C , Oemcke Rachel , Kapadia‐Kundu Nandita , Hurley Kristen , Christian Parul 
Published: November 2023

ObjectiveTo understand the facilitators and barriers to participation in a district‐wide nutrition program targeted to children 6–23 months of age in a rural district of Malawi.MethodsA qualitative study was undertaken in November‐December 2015 in the context of a nutrition program being implemented in a rural district of Malawi since 2014, providing daily lipid based nutrient supplements (Nutributter, Nutriset, France) to children and a social behavior change communications (SBCC) package of infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) messages to improve child growth. We conducted semi‐structured in‐depth interviews with mothers (n=34), fathers (n=11), and grandmothers (n=4) of children aged 6–23 months; focus group discussions (FGD) with village leaders (1 FGD of n=11) and program staff (3 FGD of n=12, n=10, and n=11, respectively); and direct observations of mothers and their children (n=12 pairs) to elicit perceptions of the program from the perspectives of mothers, households, the community and implementing organizations. Grounded theory guided all study processes. Dedoose v.6.1.18 was used for data management, coding, and analysis. Theoretical constructs from the Socio‐Ecological Model and the Transactional Model were used to summarize and present results.ResultsNutributter was viewed positively by all members of the household and community. Reports of visible changes in child health and growth were described and ascribed to the introduction of Nutributter. This consideration constituted an important determinant of program participation and adherence as households desired to participate in the program. Benefits to participation were far outweighed by perceived barriers to Nutributter. Barriers that affected participation were competing tasks or obligations that prevented travel on distribution days to collect the monthly supply of Nutributter and household‐level misuse of Nutributter despite widespread knowledge that the product was not for sharing. Limited and superficial knowledge of the SBCC IYCF and WASH messages, and lack of financial and physical access to nutritious foods constituted significant barriers to enacting desired behavioral changes among mothers. Given the difficulty of respondents to recall certain IYCF messages, such as “the six food groups”, one might conclude that these are alien to the socio‐cultural landscape of the target communities, making them even more difficult to be understood and applied.ConclusionsIn this setting of high food insecurity, a program that provides a food supplement achieved widespread acceptance and visible changes in child health and nutrition; adjustments to program distribution components and SBCC messaging for IYCF and WASH may be needed to further boost participation and drive desired changes in behavior.Support or Funding InformationThe Children's Investment Fund Foundation (CIFF) funded this study.