Evaluating malnutrition management through an intersectional lens: A case study of a community-based child malnutrition program in rural Uganda

Abstract

ABSTRACTBackgroundIn 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.MethodsThis 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.ResultsWe 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.ConclusionResults 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.KEY MESSAGEMost evaluations of community-based management of acute malnutrition programs adopt biomedical or behavioral health models, while determinants beyond caregivers’ choices, behaviors, and practices can influence the outpatient management of child malnutrition. Managers and evaluators of these programs in low- and middle-income countries should also consider healthcare and structural determinants of care, to offer holistic interventions tackling the multifaceted barriers to programmatic success.KEY MESSAGESKey FindingsPoverty and gender inequality limited caregivers’ access to healthcare and their ability to comply with community-based management of acute malnutrition (CMAM) outpatient protocol.Nutritional counseling provided to caregivers was inconsistent, often including contradictory information about the treatment prescribed to children.Caregivers of malnourished children had a limited understanding of malnutrition and its underlying mechanisms.Key ImplicationsCMAM program evaluators should look beyond individual and behavioral factors and consider how healthcare and structural determinants interact with caregivers’ behaviors in influencing children’s outpatient care.CMAM program managers should expand support offered to caregivers by implementing holistic interventions tackling the multilevel barriers to malnutrition management to maximize programmatic success.Policymakers in Uganda and other low- and middle-income countries should develop national guidelines to fight malnutrition that seek to address the underlying determinants of child undernutrition, such as food insecurity, poverty, and women’s access to education and employment.