Leveraging the Scaling Up Nutrition Movement to Operationalize Stunting Prevention Activities: Implementation Lessons From Rural Malawi.

BACKGROUND: The rural district of Ntchisi is in the central region of Malawi. Among children aged 6 to 23 months, the stunting prevalence is 40% to 50%. To address this high prevalence, the World Food Programme, with cooperating partners, supported the Government of Malawi to implement an integrated stunting prevention program entitled The Right Foods at the Right Time from 2013 to 2018. OBJECTIVE: To provide implementation lessons learned from systematic documentation of how the Scaling Up Nutrition (SUN) movement, combined with other international and national initiatives and policies, was translated into tailored programming. METHODS: During program conception, early design, and implementation, this descriptive study systematically documented the process of translating SUN principles and government policies into an operational stunting prevention program in rural Malawi. RESULTS: We identified 8 factors that contributed to successful translation of policy into program activities: (1) well-structured National SUN framework, (2) reliable coordination platforms and district ownership, (3) systematic and evidence-informed program design, (4) multiple forms of data used to inform program planning, (5) multisectoral implementation approaches to stunting prevention, (6) innovation in technology to improve overall program efficiency, (7) systematic collaboration among diverse stakeholders, and (8) strong public health nutrition capacity of program team members. CONCLUSIONS: Lessons from this nutrition program in Ntchisi, Malawi, provide one case illustrating how the SUN movement, government policies, and global evidence base can be operationalized into tailored programming for improving nutrition.

Process Evaluation of a Large-Scale Community-Based Nutrition Program in Malawi.

BACKGROUND: Global attention to the study of nutrition program implementation has been inadequate yet is critical for effective delivery and impact at scale. OBJECTIVES: The objective of this mixed-methods process evaluation study was to measure the recruitment, fidelity, and reach of a large-scale, community-based nutrition program in Malawi. METHODS: The nutrition program delivered a small-quantity lipid-based nutrient supplement (SQ-LNS) and social and behavior change communication (SBCC) to improve infant and young child feeding (IYCF) and water, sanitation, and hygiene (WASH) practices in households with children aged 6-23 mo. Program monitoring and evaluation data were used to measure program recruitment, reach, and fidelity. Structured direct observations and knowledge questionnaires with program volunteers measured quality aspects of program fidelity. The number of times activities were done correctly was used to tabulate proportions used to represent program functioning. RESULTS: Half (49.5%) of eligible children redeemed program benefits by 8 mo of age during the first 4 y of program implementation. Implementation of training activities for SBCC cadres exceeded program targets (100.6%), but the completion of certain modules (breastfeeding and complementary feeding) was lower (22.9% and 18.6%, respectively). Knowledge of IYCF, WASH, and SQ-LNS messages by volunteers was >85% for most messages, except ability to list the 6 food groups (35.7%). Structured direct observations of SQ-LNS distributions indicated high fidelity to program design, whereas those of household-level counseling sessions revealed lack of age-appropriate messaging. Program reach showed participation in monthly distribution sessions of 81.0%, group counseling of 93.3%, and individual-level counseling of 36.9%. CONCLUSIONS: This community-based nutrition program was implemented with high fidelity and quality, with specific interventions requiring further attention. The documentation of implementation contributes to our understanding about how program impacts were achieved.

Designing a SBCC Strategy for Rural Malawi Demonstrates Potential of SUN Movement.

Objectives: Nutrition programs addressing chronic malnutrition require social and behavior change communication (SBCC) that resonates with communities and addresses specific cultural and contextual challenges. The objective was to develop a culturally relevant SBCC strategy for Ntchisi district, Malawi as part of a WFP-supported government stunting prevention program. Methods: We conducted interviews with national and district-level stakeholders and reviewed materials on local nutrition-related SBCC activities. We conducted formative research using participatory community workshops, in-depth interviews, and ethnographic methods to understand infant and young child feeding (IYCF) practices and perceptions of a lipid-based nutrition supplement (LNS). We applied these findings along with knowledge from the peer-reviewed scientific literature around effective SBCC to develop an Ntchisi district-specific SBCC strategy Results: National and district-level stakeholders are united through the SUN movement to reduce stunting. The government of Malawi has a National Education and Communication Strategy (NECS) based on SUN tenants; however, most stakeholders could not articulate how to operationalize NECS. Nonetheless, by aligning with the NECs strategy, stakeholders welcomed the development of a Ntchisi-specific SBCC strategy. Results from the formative research guided the tailoring of NECs messages to generate salient communication targeting unique challenges and facilitating factors of the lean, harvest, and post-harvest seasons around IYCF Conclusions: This work demonstrated how a national-level commitment to the SUN movement can facilitate community-level operations. Supplementing SUN materials with results from formative research is necessary for context-specific and culturally-appropriate approaches to behavior change.