Understanding malnutrition management through a socioecological lens: Evaluation of a community-based child malnutrition program in rural Uganda

Abstract

Background: In Uganda, almost half of children under 5 years old suffer from undernutrition. Community-based management of acute malnutrition (CMAM) is recognized as an effective strategy for tackling this important global health issue. However, evaluations of CMAM programs are inconsistent and largely based on biomedical and behavioral health models, failing to incorporate structural factors influencing malnutrition management. Using an intersectional lens would allow to investigate the complex social processes shaping children's care in CMAM programs. The aim of this evaluation was to understand and describe factors influencing malnutrition management in a CMAM program in rural Uganda, situating its findings within their social contexts using an intersectional approach. Methods: This evaluation used qualitative methods to identify determinants linked to caregivers (micro-level), healthcare (meso-level) and societal structures (macro-level) that can influence children's outpatient care. Data were collected from September to December 2019 at a community clinic through observations and interviews with caregivers of malnourished children. Data were coded in NVivo using thematic analysis. Intersectionality informed the interpretation of findings. Results: We observed 14 caregiver-provider encounters and interviewed 15 caregivers to assess factors hindering outpatient malnutrition management. Findings showed that caregivers had limited understanding of malnutrition and its mechanisms. The counselling offered was inconsistent and information given to caregivers about treatment preparation at home was insufficient. Gender inequality and poverty limited caregivers' access to healthcare and their ability to care of their children. Factors at the micro and meso levels intersected with structural factors to influence malnutrition management. Conclusion: Results suggest that CMAM programs would benefit from expanding support to caregivers by providing holistic interventions tackling structural barriers to children's care. Using an intersectional approach to program evaluation could support improvement efforts by moving beyond individual determinants to address the social dynamics shaping the outpatient management of malnutrition in low- and middle-income countries.