[MCH LitRev/1]

FAMSA MCH – Literature Review- Nutrition & MCH 2014
Acknowledgements
The literature review was compiled for FAMSA by Dr Joy Summerton from Okuhlekodwa Research and
Development Consultants, with financial support from the the Reducing Maternal and Child Mortality through Strengthening Primary Health Care in South Africa (RMCH) Programme. The RMCH programme is implemented by GRM Futures Group in partnership with Health Systems Trust, Save the
Children South Africa and Social Development Direct, with funding from the UK Government. www.rmchsa.org
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FAMSA MCH – Literature Review- Nutrition & MCH 2014
1.
Introduction ..................................................................................................................................... 5
2.
Health seeking behaviour ................................................................................................................ 5
2.1
Antenatal care (ANC) ................................................................................................................. 5
2.2
Postnatal care and growth monitoring ..................................................................................... 6
3.
Infant feeding practices ................................................................................................................... 7
3.1
Social factors that contribute to harmful infant feeding practices ........................................... 7
3.2
Economic factors that contribute to harmful infant feeding practices..................................... 9
4.
Summary ........................................................................................................................................ 11
5.
Conclusion ..................................................................................................................................... 14
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FAMSA MCH – Literature Review- Nutrition & MCH 2014
HST
IFSNP
IFSS
IMCI
INP
LBW
MBFHI
MCH
MDG
MNCWH
MSP
MTEF
NFES
NPO
NTP
OVC
PEM
Acronyms
AFASS
AIDS
ANC
CHW
DoSD
ECD
EPI
FAMSA
FBSA
FFP
HIV
PHC
PMTCT
RMCH
SPFS
UNICEF
WHO
Acceptable, Feasible, Affordable, Sustainable and Safe
Acquired Immune Deficiency Syndrome
Antenatal Care
Community Health Worker
Department of Social Development
Early Childhood Development
Expanded Programme in Immunization
Family and Marriage Society of South Africa
Food Bank of South Africa
Food Fortification Programme
Human Immunodeficiency Virus
Health Systems Trust
Integrated Food Security and Nutrition Programme
Integrated Food Security Strategy
Integrated Management of Childhood Illnesses
Integrated Nutrition Programme
Low Birth Weight
Mother and Baby Friendly Health Initiative
Maternal and Child Health
Millennium Development Goals
Maternal Newborn Child and Women’s Health & Nutrition
Micronutrient Supplementation Programme
Medium Terms Expenditure Framework
National Food Emergency Scheme
Non-profit Organisation
Nutrition Therapeutic Programme
Orphaned and Vulnerable Children
Protein Energy Malnutrition
Primary Health Care
Prevention of Mother to Child Transmission
Reducing Maternal and Child Mortality through Strengthening Primary Health Care
Special Programme for Food Security
United Nations Children’s Fund
World Health Organisation
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FAMSA MCH – Literature Review- Nutrition & MCH 2014
FAMSA Limpopo, in partnership with CHoiCe Trust, received two grants from the Reducing Maternal and Child Mortality through Strengthening Primary Health Care (RMCH) Programme to carry out multistakeholder consultatations and further explorations that would contribute to improved uptake of maternal and child health services. The goal was to to improve the health outcomes of women and children in the Waterberg and Capricorn Districts of Limpopo.
This literature review responds to the quest to understand the linkages between nutrition and maternal and child health, with a specific focus on caregiver behaviour related to infant and child malnutrition in South Africa. As such, the literature review seeks to explore, from a consumer perspective, the various factors that inhibit the attainment of good nutritional status. Accordingly, the focus is on community (including patient and caregiver) behaviour including but not limited to: 1) feeding practices that contribute to the onset of and sustained high levels of under nutrition, wasting and stunting amongst children under five years of age; and 2) health seeking behaviour in respect to the demand, access and uptake of MCH public health facilities at the district level when a child is showing the signs of malnutrition. The review ends with a summary of the key interventions in the
Integrated Nutrition programme (INP) along the continuum of care for children, starting from conception to 5 years and with a specific focus on community-based interventions. Challenges that hamper the interventions yielding the desired results, with specific reference to utilisation of services
(uptake), are discussed.
While infant nutrition begins with the nutritional health of the woman prior to and during pregnancy, this consideration was beyond the scope of this exercise which is confined to after the birth and under the age of five. The intention was to identify national level patterns in respect to the above, and distil, where possible, what the literature reveals about provincial patterns, peculiarities and outliers.
A large number of documents which included peer reviewed journal articles, technical reports, notes from workshops and consultations, policies and strategies related to nutrition and child health were collected and read. The focus was on literature published over the period 2008-2013. A list of documents consulted is included in the references. This literature review [MCH LitRev/1] is developed simultaneously with a second complementary literature review on culture and maternal and child health. Cultural barriers to improving the nutritional status of children 0-5 years are discussed in MCH
LitRev/2.
In spite of government efforts, namely policies, programmes, human resource development and systems strengthening, to curb malnutrition and improve the health outcomes of children under five years, high infant morbidity and mortality directly related to malnutrition are sustained. Some of the barriers to effectively addressing malnutrition in South Africa are discussed below.
Antenatal care is prime opportunity to educate pregnant women about maternal nutrition, including providing them with micronutrient supplements and controlling nutritional deficiencies. It is
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FAMSA MCH – Literature Review- Nutrition & MCH 2014 estimated that 12% of neonatal deaths could be averted through antenatal care at 90% coverage 1 . For purposes of this literature review, antenatal care services refer to those from non-traditional health care practitioners. The health seeking behavior of pregnant women is influenced by accessibility of health care, household income and perception of pregnancy. Some women who do not associate pregnancy with ill-health are less likely to seek health care as health care is directly associated with curative services. The decision to attend antenatal care is further influenced by low household income.
Limited resources are prioritized for perceived basic needs such as curative care, food, etc. as opposed to paying for transportation costs for preventative care. Long waiting hours at health care facilities for preventative care also do not serve as strong enough motivation to attend antenatal care. Women also weigh the risks associated with attending antenatal care. Poor roads and long distances, which are associated with placing a pregnant woman at risk, reduces the likelihood of attending antenatal care. The likelihood of the utilization of antenatal care services is further reduced if the attitudes and behavior of health care workers are perceived to be negative 2 3 . As a result of these perceptions, pregnant women miss the opportunity to receive important education and counselling about good nutrition, including receiving micronutrient supplements (e.g. iron and folic acid) that will improve the health outcomes of neonates (e.g. prevent spinal bifida and underweight in newborns).
The protection, promotion and support of breastfeeding is a key intervention for child survival, yet an estimated 8% of women exclusively breastfeed, with a mere 1.5 babies between four and six months being exclusively breastfed in South Africa 4 . In a study conducted in a periurban community in the
Western Cape, 0% of mothers exclusively breastfed; 78% were practicing complementary breastfeeding; and 32% of infants had received complementary foods by the first month of life 5 . One of the factors that inhibit breastfeeding includes lack of sufficient knowledge about the benefits of breastfeeding, especially exclusive breastfeeding. ANC and postpartum care provide a vehicle for imparting information to increase knowledge about breastfeeding. Non-attendance of ANC results in pregnant women not acquiring information and thus adopting sub-optimal breastfeeding practices.
Even in the event that information is imparted either at a health facility or within the community, such knowledge is often inaccurate or lacks detail to ensure that it is internalized by mothers. One study in
KwaZulu-Natal revealed that CHW, who are responsible for nutrition education, had a lack of knowledge about breastfeeding and complementary feeding. Most of the caregivers (82%) in the
1 Titaley, C.R., Dibley, M.J. and Roberts, C.L. 2010. Factors associated with underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey 20002/2003 and 2007.
Biomed Central Public Health. 10:485
2 Titaley, C.R., Dibley, M.J. and Roberts, C.L. 2010. Factors associated with underutilization of antenatal care services in Indonesia: results of Indonesia Demographic and Health Survey 20002/2003 and 2007.
Biomed Central Public Health. 10:485
3 Finlayson, K. and Downe, S. 2013. Why do women not use antenatal services in low- and middle-income countries? A meta-Synthesis of qualitative studies
4 Department of Health, Medical Research Council, and OrcMacro. 2003. South African Demographic and
Health Survey 2003. Pretoria: National Department of Health. http://www.gov.za/
S ibeko, L., Dhansay, M.A., Charlton, K.E., Johns, T. and Gray-Donald, K. 2005. Beliefs, attitudes and practices of breastfeeding mothers from a periurban community in South Africa. Journalof Human Lactation 21 (1):
31-38
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FAMSA MCH – Literature Review- Nutrition & MCH 2014 study stated that solid foods should be introduced between 4-6 months, and 35% were of the opinion that special baby foods were of a better nutritional value than ordinary (fresh) foods 6 .
In addition, women are discharged soon after birth (approximately 6 hours), which does not provide adequate time for counselling and support to ensure breastfeeding is fully established. Confusion surrounding breastfeeding for HIV-positive mothers contributes to nutritional vulnerability during the most critical phase, 0-23 months, due to poor breastfeeding and complementary feeding practices.
Due to inadequate information, HIV-positive mothers tend to assume that they will transfer the virus to their infants through breastfeeding. They thus adopt formula feeding often in settings with lack of access to clean water.
Growth monitoring is an important aspect of reducing and managing malnutrition, and forms part of the Expanded Programme on Immunization (EPI). Through routine visits to health facilities (baby wellness clinic), children are assessed for malnutrition and caregivers are given appropriate nutrition education. In a study in the Eastern Cape, the majority of caregivers of children who were hospitalized for severe malnutrition were able to recall nutrition information that they had acquired in hospital, yet they were unable to apply their knowledge because of a lack of food and income at home. The children of the caregivers were found to be in a cycle of poverty, disease and malnutrition. In the absence of breaking this cycle, these children will be unable to reach their full potential of physical and mental development.
This section seeks to unearth and highlight prevalent infant feeding practices that pose a challenge to
South Africa achieving the MDG of reducing infant and child mortality by 2015.
Three categories, based on causation, are used to discuss harmful infant feeding practices, namely i) social; ii) economic and iii) cultural. The second complementary literature review produced by FAMSA and Choice Trust under the RMCH grant, on culture [MCH LitRev/2] provides a comprehensive discussion on the impact of culture on maternal and child health. Hence, it is not discussed in detail in this literature review.
It is almost a norm in particularly rural areas for infants to be introduced to solids from as early as the first week of life. In many instances, it is believed that breast milk, mainly due to its liquid form, is not adequate to fulfill hunger in an infant. This is based on the mother’s perception that their infant is not satisfied by breast milk alone. The notion of the inadequacy of breast milk is linked to infants perpetually crying, interrupted sleep, and observed inadequate quantity of breast milk. The common practice is for breast milk to be supplemented with a soft porridge that is prepared in a liquid consistency. A study conducted in the Eastern Cape revealed that 45% and 55% of mothers who chose exclusive breastfeeding and exclusive formula feeding respectively during the antenatal period, had changed their choice of feeding practices after 6 weeks of birth. When comparing, all the HIV-positive mothers had maintained the infant feeding method selected before delivery, whilst 50% of all the HIV-
6 Faber, M. and Benade, A.J.S. 2007. Breastfeeding, complementary feeding and nutritional status of 6-12month-old infants in rural KwaZulu-Natal. South African Journal of Clinical Nutrition. 20 (1): 16-24.
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FAMSA MCH – Literature Review- Nutrition & MCH 2014 negative mothers had changed the infant feeding method selected before delivery. Of the exclusive breastfeeding group, 21.1% also gave the infants water, as did 26.8% of the exclusive formula feeding group 7 .
About 73% of mothers in a study conducted in Limpopo introduced solids to their infants before four months. In one other study in KwaZulu-Natal, 61% of infants received solid foods before the age of 4 months. The most common solid was a traditional maize-based porridge (Tshiunza in Venda) that was introduced immediately after birth. In KwaZulu-Natal, a harder maize-based porridge called Phuthu is also given 8 9 . Even with the appropriate introduction of complementary foods after 6 months, one type of food is usually introduced, which does not provide all the necessary nutrients. One study in
Limpopo showed that almost 40% of infants received only carbohydrates as complementary food 10 .
This is of particular concern considering the vast amount of nutrient rich foods available in some parts of Limpopo. For example in Venda, where the study was conducted, nutrient rich fruits and vegetables such as avocados and peanuts are in abundance and accessible, yet are not included in the diets of children.
The National Policy on breastfeeding unequivocally stipulates exclusive breastfeeding for the first 6 months of life. In the case of HIV-positive mothers, policy guidelines recommend either exclusive breastfeeding or exclusive formula feeding and strongly condemn MIXED feeding, which is the interchangeable use of breastfeeding and formula feeding. However, exclusive breastfeeding or formula feeding is often unrealistic and unfeasible in many households. For one, the labour laws provide for 4 months of paid maternity leave and young mothers that are learners are required to return to school as soon possible post birth. In the informal labour market, mothers often do not enjoy maternity benefits and are thus also required to return to work as early as possible post birth. Some mothers are employed away from home and only able to return home on weekends. In such cases, even when working mothers and learners have all intensions of exclusively breastfeeding, they may not be able to sustain their feeding practice of choice and thus resort to mix feeding.
In the Eastern Cape, mothers gave various reasons for changing the infant feeding method selected before birth. The majority of mothers (50%) changed their method of infant feeding because they were students going back to school, 25% were going back to work, whilst the rest, collectively 25% gave other reasons, including constipation of the infant due to breastmilk, painful breasts and advice from significant others 11 . There is a plethora of evidence that substantiates the fact that women in low-income settings are often not the only decision maker pertaining to the wellbeing of an infant.
Mothers (grannies) and mothers-in-law often have a significant influence on decision making
7 Yako, E.M. & Nzama, N.P.B. 2013, Maintenance of the selected infant feeding methods amongst postnatal mothers at risk of HIV in the Eastern Cape Province, South Africa. Health SA Gesondheid 18(1): 585-591
8 Mushaphi, L.F., Mbhenyane, X.G., Khoza, L.B., Amey AKA, M.A. 2008. Infant-feeding practices of mothers and the nutritional status of infants in the Vhembe District of Limpopo Province. South African Journal of
Clinical Nutrition 21 (2): 36-41.
9 Faber, M., Spinnler Benadé, A.J. 2007. Breastfeeding, complementary feeding and nutritional status of 6-
12 month old infants in rural Kwa-Zulu Natal. South African Journal of Clinical Nutrition 20 (1): 16-24.
10 Zöllner, E. and Carlier, N.D. 1993. Breast-feeding and weaning practices in Venda, 1990. South African
Medical Journal 83: 580 - 583.
11 Yako, E.M. & Nzama, N.P.B. 2013, Maintenance of the selected infant feeding methods amongst postnatal mothers at risk of HIV in the Eastern Cape Province, South Africa. Health SA Gesondheid 18(1):
585-591
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FAMSA MCH – Literature Review- Nutrition & MCH 2014 pertaining to infant feeding practices, making it difficult for mothers of infants and children under five to translate their knowledge into practice.
Anecdotal evidence also points to some young girls and women opting not to breastfeed due to the unfounded belief and fear that breastfeeding will lead to sagging of the breasts. This fear is more prominent in urban and more affluent segments of society where breasts are strongly associated with western ideologies of beauty, sex and sexuality as opposed to rural communities such as in the Eastern
Cape, KwaZulu-Natal and North West where women of all ages proudly expose their breasts of varying shapes and sizes in public either through their traditional attire or when breastfeeding.
Female breasts have different connotations in different cultures, with industrialised societies more prone to associating female breasts with sexual activity. Based on this view, the primary function of female breasts is related to sexual behaviour and pleasure and thus breastfeeding should be practiced in private, as with sexual behaviour. This view diminishes support for breastfeeding which adversely impact women initiating and sustaining breastfeeding, especially exclusive breastfeeding during the first 6 months of life. In many developing civilisations female breasts do not create sexual associations both in men as well as in women. In these societies and cultures, the breast has maintained the primary biological function, which is to feed neonates and babies 12 .
The national policy on infant and young child feeding states that, in exclusive feeding, the baby should only be given medication in addition to the chosen feeding method. Giving the infant additional fluids puts such an infant at risk of malnutrition 13 . In many instances, mothers who opt to exclusively formula feed in the antenatal period are unable to sustain this practice due to various reasons, some of which are economic. An example in point is a study in the Eastern Cape where some mothers who opted to exclusively formula feed were unable to buy formula due to them being unemployed or earning a low salary 14 . One of the methods used by mothers to counter the inability to buy formula is to reduce the amount of formula used to prepare a bottle feed in order for the formula to last longer. This practice reduces the recommended nutrient intake of the child and thus renders the child vulnerable to malnutrition. A study in the Western Cape revealed that 45% of mothers over diluted and 10% of mothers under diluted formula milk. The reason cited for over diluting formula milk was that mothers could only afford a limited number of formula tins per month and often relied on grants or other people for financial support. Some mothers reported to add cooked porridge or ‘meelbol’ (cake or bread flour that is scorched brown and cooked like soft porridge) to the over diluted formula milk to save milk. Water, infant cereal or rooibos tea was also given to infants in the absence of adequate formula milk 15 .
12 Dettwyler, K. A. 1995. Beauty and the beast: The cultural context of breastfeeding in the United States.
In Stuart-Macadam, P & Dettwyler, K.A. (Eds.). Βιocultural Perspective. New York, Aldine De Gruyter.
13 National Department of Health 2007. Infant and young child policy. Pretoria: Department of Health.
14 Yako, E.M. & Nzama, N.P.B. 2013, Maintenance of the selected infant feeding methods amongst postnatal mothers at risk of HIV in the Eastern Cape Province, South Africa. Health SA Gesondheid 18(1):
585-591
15 Goosen, G., McLachlan, M.H. and Schübl, C. 2014. Infant feeding practices during the first 6 months of life in a low-income area of a Western Cape Province. SAJCH 8 (2): 50-54
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FAMSA MCH – Literature Review- Nutrition & MCH 2014
Cash transfers are a poverty reduction strategy used to curb malnutrition. In South Africa the Child
Support Grant (CSG) is issued to eligible children and as of October 2014 it is R320 per month. There is substantial evidence of the positive impact of the CSG on the nutritional, educational and health outcomes of children under 5 years and above 16 . However, the actual use of the CSG varies across caregivers of recipients, from use specifically for food for children, to use for clothes, education and other personal expenses. A national study revealed that although the CSG was predominantly used for school related expenses of the child and general household food, it was also used for other purposes by primary caregivers. Other less frequently reported uses include clothing, beauty or hairdressing, transport, health care, debt, burial societies and investments. Burial societies and investments were specific to Limpopo. The misuse of the CSG was reported by both recipients and caregivers. The most common misuse of the CSG was by either grannies or biological parents who use the CSG for their personal use such as alcohol, clothes and other non-essential items and uses. Some young mothers are reported to abandon their young children in the care of grandmothers without relinquishing control of the CSG. The grandparents are thus expected to utilize their old age pension
(OAP) to care for the children. Some grandparents who are the primary caregivers of recipients of the
CSG reportedly also misuse it by buying alcohol instead of providing for the needs of children 17 .
In spite of the misuse of the CSG, it is a critical source of income to address the nutritional needs of children. However, many eligible children are unable to access the grant due to not meeting the administrative requirements such as not having a birth certificate or identity document (ID).
16 DSD, SASSA and UNICEF. 2012. The South African Child Support Grant Impact Assessment: Evidence from
a survey of children, adolescents and their households. Pretoria: UNICEF South Africa
17 Department of Social Development, South African Social Security Agency and UNICEF 2011. Child
Support Grant Evaluation 2010: Qualitative Research Report. Pretoria: UNICEF South Africa
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FAMSA MCH – Literature Review- Nutrition & MCH 2014
In spite of the policy frameworks, strategies and programmes that have been put in place by the South African government in an effort to eradicate malnutrition, especially amongst children under five years of age, under nutrition continues to threaten achievement of the MDGs (1, 4 and 5). The lived reality (social, economic and cultural) of a community and caregivers of children, impacts on health seeking behaviour and feeding practices that adversely affect a child’s nutritional status. Failure to take cognisance of these lived realities in the design and implementation of government policies, strategies and interventions to address infant and child malnutrition, could hamper desired outcomes and thus jeopardise the attainment of MDG 4.
Table 1 below summarises key interventions in the Integrated Nutrition Programme (INP) and along the continuum of care for children, starting from conception to 5 years and with a specific focus on community-based interventions. Challenges that hamper the interventions yielding the desired results, with specific reference to utilisation of services (uptake), are also discussed.
CONTINUUM OF CARE
Pre- and conception/ANC post-
INP PILLAR
 Food fortification
 Micronutrient supplementation
 Nutrition rehabilitation in communities
INTERVENTION
 Nutrition assessment of pregnant
 women
Maternal nutrition through BANC- including iron-folate and calcium supplementation and education on maternal diet
 Counselling on appropriate infant feeding practices
 Counselling on newborn and child care including appropriate infant and young child feeding
CHALLENGES (non-culture related)
 Pregnant women do not associate pregnancy with ill-health and thus do not see the need to consult a health care provider in the absence of illness. This amidst lack of resources to access health care (e.g. transport) and long waiting hours at health care facilities. Thus pregnant women do not receive the necessary micronutrient supplementation and dietary counselling from BANC.

Pregnant women from impoverished households and who are vulnerable to food insecurity do not have access to food and vegetables rich in nutrients required during pregnancy. One study in
KwaZulu-Natal revealed that Vitamin A deficiency in women and children in one village was attributed to the absence of Vitamin A rich foods at local shops 18 .
 Home gardens as a means to improve maternal malnutrition and child undernutrition is hampered by limited access to water supply, relatively high costs for seeds, fertiliser, and fencing for protection from animals.
18 Faber, M., Phungula, M.A.S., Venter, S.L., Dhansay, M.A. and Benade, A.J.S. 2002. Home gardens focussing on the production of yellow and dark-green leafy vegetables increase the serum retinol concentrations of 2-5-y-old children in South Africa. American Journal for Clinical Nutrition 76: 1048-54.
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Postnatal
FAMSA MCH – Literature Review- Nutrition & MCH 2014
Infancy/childhood
 Breastfeeding promotion
 Food fortification
 Micronutrient supplementation
 Nutrition rehabilitation in communities
 Breastfeeding promotion
 Growth monitoring and promotion


Food fortification
Micronutrient supplementation

Nutrition rehabilitation in communities
 Nutrition management
 during illness
Hospital based management of severe malnutrition
 Nutrition assessment of post-partum mothers and maternal nutritional counselling

Counselling and support for early initiation and exclusive breastfeeding
 High-dose Vitamin A supplementation for 6 to 59 months children
 Appropriate management of breast conditions
 Nutritional assessment of infants

Counselling on IYCF/EBF, maternal nutrition
 Ensuring that preventative services are accessed: vitamin A, deworming, growth monitoring linked to counselling on IYCF
 Mothers are often discharged from hospital soon after giving birth without adequate time to establish breastfeeding with the supervision and support of health care providers

Mothers do not return for postnatal care to receive health education about appropriate nutrition for lactating mothers and support for exclusive breastfeeding. This is often due to perceived absence of illness, limited resources to access health care, attitudes of health care providers and waiting times at health care facilities.

Health care providers often impart information without effectively explaining the causal-effect relationship between infant feeding practices and health outcomes. In the absence of a comprehensive understanding of the implications and linkage between good feeding practices and health outcomes, mothers are unlikely to internalize and subsequently adopt good feeding practices.
 Mothers do not necessarily understand undernutrition, wasting and stunting, nor can they accurately identify it in their children.
 In the event that a child is emaciated, mothers are sometimes reluctant to take the child to a health care facility due to fear of being judged by other mothers or negative reactions from healthcare providers

Some health care workers are not fully knowledgeable about infant feeding practices especially with developments in the field (e.g. nutritional information in the Road to Health book), and thus do not provide mothers with comprehensive and accurate information
 Information about breastfeeding is often not accurately and clearly communicated to mothers. As a result, the importance of exclusive and sustained breastfeeding is not clear to the mother. The situation is exacerbated by equivocal messages regarding breastfeeding and
HIV. Many HIV-positive mothers opt to formula feed their babies to eliminate risk of mother to child transmission. This often occurs in the absence of access to clean water.
 The notion of preventative care is not well understood by mothers, especially in the midst of limited resources which need to be shared amongst perceived priorities such as curative care and basic needs.
Hence, in the absence of illness, mothers who lack adequate knowledge about immunization and growth monitoring as determinants of child morbidity and mortality will not access such services.
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FAMSA MCH – Literature Review- Nutrition & MCH 2014
 Information about infant and child feeding practices from the health system is often in competition with information from others, particularly grandmothers
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FAMSA MCH – Literature Review- Nutrition & MCH 2014
Health seeking behavior and feeding practices are determined by socio-economic and socio-cultural factors. Policies, programmes, strategies and interventions aimed at reducing malnutrition amongst children should be informed by local dynamics and behaviours in order to provide services that are relevant, acceptable and tailor-made for the intended beneficiaries. This necessitates a process of realigning policies and interventions based on beneficiary behavior and the local context in order to successfully reduce malnutrition amongst children under five years.
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