Food supplements to reduce stunting in Pakistan: a process evaluation of community dynamics shaping uptake

Background: There is an increasing interest in use of food supplements to prevent stunting, however evidence from trials remains inconclusive meriting qualitative examination of barriers and synergies for supplement use by targeted groups. We contribute evidence on factors influencing community uptake of food supplements to feed into the design of future food supplementation programs for countering stunting. Methods: A process evaluation was undertaken of a stunting prevention food supplementation pilot in rural Pakistan that distributed wheat soy blend (WSB) to pregnant & lactating women, and lipid-based nutrient supplement (LNS) and micronutrient powder (MNP) to <5 years children. We investigated community uptake applying five parameters: value, acceptability, receipt of supplement, usage by target group, correct dosage used. Mixed methods were used: survey of 800 households, 18 FGDs with male and female caregivers, 4 FGDs with community health workers (CHWs), 22 key informant interviews with district stakeholders. Results: Survey findings showed that proportionately few beneficiaries consumed the full dose of supplements –, despite reasonable knowledge levels amongst caregivers. Sharing of supplements with other household member was common, and full monthly stock was not received by several beneficiaries. Qualitative findings revealed caregivers did not associate food supplements with stunting reduction. WSB was well accepted as an extra ration, LNS was popular due its chocolaty taste and texture, whereas MNP sprinkles were perceived to be of little value and also mistrusted. Cultural food practices led to common sharing, whereas interaction with CHWs was minimal for nutrition counselling. Qualitative findings also indicated CHW related programmatic constraints of low motivation, multi-tasking, inadequate counselling skills and weak supervision. Conclusion: We conclude that community acceptability of food supplements does not translate into optimal consumption. Instead a greater emphasis is needed on demand creation amongst caregivers and moving from sole reliance on CHWs to a broadening of food delivery and behavioural change options.