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.

While an estimated 45% of pregnant women in Malawi are anaemic, only 33% take iron tablets for a minimum of 90 days during pregnancy. The study explored the capacity of health facilities and communities to strengthen antenatal iron folate supplementation in Ntchisi, to support the achievement of Malawi’s nutrition target on halving anaemia in women of reproductive age by 2025. This qualitative study employed systematic random and purposeful sampling. Eight Focus Group Discussions with mothers of children 0-23 months, eight with Care Group volunteers and eight in-depth interviews with Village Health Workers (Health Surveillance Assistants) were conducted in each village falling within the catchment area of each of 8 health facilities. Health facilities had been sampled each from the 7 Traditional Authorities with the district hospital and direct observations had been conducted at each for antenatal care service delivery. 10 key informants from the health facilities and the District Health Office were interviewed. Thus a total of 16 FGDs, 8 HSA interviews, and 10 key informant interviews provided the data analysed in this paper.  Data were analysed manually using thematic framework analysis. Poor access to and follow up of antenatal care at the health facility has limited access to iron folate supplements, as the health facility is the main source of Iron folates. Recurrent depletion of stock of iron folate were reported by mothers at most health facilities. Consumer demand for the tablets was low due to side effects, poor acceptability, associated myths, forgetfulness and frustration from having to take a daily medication. There was limited training and education materials at the health facility and community with inadequate support given to women. The absence of clear policies and guidelines on iron folate supplementation resulted in inconsistencies in messaging. Uptake and adherence were not routinely monitored. There is a need to improve the main building blocks of the iron folate programme, including the: delivery system, tablet supply, patient education, consumer demand, monitoring and evaluation and policy.

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.

Study ObjectiveWe sought to identify barriers and preferred behavior change communication (BCC) strategies for introducing a 20‐gram lipid‐based nutrient supplement (LNS) for children 6 – 23 monthsMethodsThe formative research had 3 iterative phases, including participatory community workshops (CW) among male and female participants over 8 weeks in each setting. In Malawi, 8 CW were conducted with a total of 136 people. In Mozambique, 13 CW were carried out among Macua (n = 6) and Mwani (n = 7) participant groups with a total of 228 people. Each CW included 13 ‐ 23 participants (mean = 17.2) and served as a forum for brainstorming and voting for BCC strategies. Simple frequencies were tallied for analysis.ResultsIn Malawi, community members put the onus on female caregivers to ensure LNS would be used appropriately and preferred to receive messages about LNS through community groups (Care Groups) and health workers. In Mozambique, Macua community members preferred personal forms of BCC whereas Mwani participants preferred less personal means. While both cultural groups agreed that village chiefs, activistas, and traditional healers should be central to BCC efforts, Macua communities preferred interpersonal channels such as “associations of caregivers” but Mwani community members voted for radios and megaphones as preferred channels.ConclusionUsing participatory CW in a bottom‐up approach to intervention development may enhance likelihood of community engagement and ownership, and contribute to successful nutrition outcomes among vulnerable populations.Funded by Children's Investment Fund Foundation

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