Factors Influencing Child Feeding Practices Related to Home Fortification With Micronutrient Powder Among Caregivers of Under-5 Children in Bangladesh

Abstract

Background:

Anemia is a major public health concern in Bangladesh, affecting about 51% of under-5 children. There are a number of strategies to overcome this micronutrient-deficiency burden, and home fortification (HF) with micronutrient powder (MNP) is one of them.

Objective:

As part of an evaluation of an HF with MNP intervention program, we conducted a qualitative study to understand the factors influencing demand, purchase, and utilization of MNP by caregivers of under-5 children.

Methods:

We purposively selected study participants from 5 subdistricts and 1 urban slum in Bangladesh where HF with Pushtikona (a brand name of MNP) program is available. Data were collected through household observations and conducting in-depth interviews and focus group discussions with caregivers, grandmothers, and fathers of under-5 children.

Results:

Our study showed that caregivers were initially cautious, using Pushtikona on a trial basis, and afterward they employed various strategies to get their children to eat food fortified with Pushtikona. Barriers to acceptance and use of Pushtikona included inappropriate initiation of complementary feeding, discouragement from influential family members as well as miscommunication, conflicting information, and irregular visits by the health workers who sell Pushtikona to caregivers. Based on these findings, we characterized the users of Pushtikona as regular, ever, irregular, and never.

Conclusion:

The evidence suggests that focusing on counseling caregivers and other family members on the importance of MNP and on age-appropriate feeding practices will be critical to the success of this intervention program as will regular visits by health workers and improved service delivery.

Introduction

Anemia is a major public health concern in Bangladesh, affecting about 51% of children younger than 5 years of age. ¹ Nutritional deficiencies, infections, and blood disorders are the main causes of anemia. ² In Bangladesh, anemia is more prevalent among children of poor and middle-class families than among children of rich families. ³ Feeding practices affect child growth and, at a population level, play an important role in determining the prevalence of anemia. ⁴ In Bangladesh, caregivers generally feed young children small quantities of food with low micronutrient density. Both the small quantity and the low quality of food fed to children lead to their low intake of micronutrients during the second half of infancy (6-12 months of age). ⁵ Moreover, complementary feeding practices are well below the international standards: Less than 14% of infants consume the minimum recommended diversity in food groups, and only 6% meet the criteria for minimum acceptable diet. ⁶

There are a number of strategies to overcome this burden of micronutrient deficiency, and home fortification (HF) is one of them. Some interventions have found that HF of foods with multiple micronutrient powder (MNP), along with the promotion of age-specific home-based complementary feeding, is an effective strategy for reducing childhood iron-deficiency anemia. ^{7 –9} The World Health Organization (WHO) recommends HF of foods with MNP to improve iron status and reduce anemia among infants and children in settings where iron supplementation is not widely implemented and is not cost-effective, where the prevalence of anemia in children younger than 5 years of age is 20% or higher, and in low- and middle-income countries. ⁸ Following the WHO guidelines, MNP HF interventions have been implemented in many low- and middle-income countries. ¹⁰ Systematic reviews suggest that commercially processed HF products, including MNP and lipid-based nutrient supplements, can significantly increase the concentration of hemoglobin and ferritin and can reduce the risk of anemia. ¹¹

Based on this evidence, the Children’s Investment Fund Foundation (CIFF), United Kingdom, is supporting collaboration with the Global Alliance for Improved Nutrition (GAIN) and Bangladesh Rural Advancement Committee (BRAC), to implement a nationwide community-based HF with MNP program to reduce the high prevalence of anemia by improving the nutritional status and feeding practices of under-5 children in Bangladesh. The goal of the program is to reduce the prevalence of anemia among under-5 children by at least 10% by the end of the project. Pushtikona (a brand name of MNP) is available for purchase from BRAC’s frontline volunteer health workers, the Shasthya Shebikas (SS), in rural and urban–slum areas to the caregivers of under-5 children. The SSs are volunteer health workers who buy BRAC products (such as iodized salt, soap, oral saline, contraceptive pill, etc) and sell them to the community with a profit margin. Under the HF with MNP Program, BRAC sells Pushtikona to an SS at Bangladeshi Taka (BDT) 1.5 (US$0.02) per sachet and asks the SS to sell it to the caregivers at BDT 2.5 (US$0.03) per sachet. In addition to selling the Pushtikona, the SS offers caregivers nutrition education and counseling to ensure their compliance with HF using Pushtikona.

Demand, purchase, and utilization of HF with MNP varied in different low- and middle-income country settings, where the expected outcomes of the intervention program have still not been achieved due to a number of associated factors. In Bangladesh, an analysis of secondary data sources identified factors such as traditional feeding practices, lack of awareness on HF with MNP among the caregivers, limited skills of community health workers, and lack of household-level compliance as barriers to HF with MNP; constant interactions between families and frontline health workers was identified as an enabler of HF with MNP. ¹² A cross-sectional study of the HF with MNP program in Bangladesh assessed factors associated with adherence to MNP, such as whether households belonging to the poorer, middle, and richer wealth quintiles were significantly associated with having high adherence to MNP and also stated the limitation in the interpretation of the findings and suggested a qualitative inquiry for more insightful results. ¹³ However, both of these studies called for context-specific, in-depth investigation for evidence-based course correction and scaling up of promotional intervention activities of MNP HF program.^12,13 There has been a paucity of qualitative in-depth exploration of factors influencing demand and purchase of MNP and utilization of market-based HF of MNP in child feeding practices in Bangladesh. As part of the larger evaluation of an HF with MNP Program in Bangladesh, we conducted a qualitative study to understand the factors that influence HF with MNP and the child-feeding practices of caregivers of under-5 children.

Methods

We conducted an exploratory qualitative study in March to June 2014, with caregivers of under-5 children and with household influencers of those caregivers. We collected data from grandmothers, caregivers, and fathers of under-5 children using multiple data collection tools, such as tailored interviews and discussion guides, for triangulating the findings.

Ethical Approval

The study was approved by the icddr, b institutional review board (IRB), which is comprised of the research review committee and the ethical review committee. Written informed consent was taken from all of the participants before starting the interview or discussion.

Study Site

We collected data from 5 upazilas (subdistricts) of Bangladesh: Balaganj of Sylhet, Ulipur of Kurigram, Satkania of Chitagong, Monirampur of Jessore, and Gaffargaon of Mymensing district and an urban slum called Begunbari within Dhaka City Corporation. These sites were selected purposively based on population coverage by the nutrition intervention of HF with Pushtikona program and the availability of BRAC’s community-based service providers.

Sample

Study participants were caregivers of the targeted children (who were primarily the biological mothers and fed most of the meals). We also conducted interviews with grandmothers and fathers of under-5 children. Participants of the study were recruited purposively based on their Pushtikona usage. For example, regular users started feeding Pushtikona at least a month before the interview date and had used it within the preceding 30 days before the interview date; irregular users started feeding Pushtikona at least a month before but did not feed regularly; ever users fed Pushtikona at least 1 time during their child’s life but no more; and never users had never fed Pushtikona during their child’s life. In addition, we also considered caregivers’ sociodemographic characteristics and interactions with BRAC’s SS. To recruit study participants, the interviewers of this study went to the respective communities of the SSs and searched for children aged 6 to 59 months. We then talked with caregivers (primarily biological mother), grandmothers, and fathers of these children and compiled a list of potential participants in accordance with the purposive criteria and objectives of this study. Grandmothers and fathers were also selected to participate in the study, since they influence household decision-making. We planned to conduct 42 to 60 in-depth interviews with caregivers and grandmothers, 6 focus group discussions (FGDs) with fathers, and 21 household observations in the selected study sites. The number of interviews was equally distributed among the 6 study sites. However, the final sample size was based on the principle of achieving data saturation from each of the different groups of study population.

Study Procedures

The principal investigator (PI; first author) assembled a skilled and experienced 9-member team for data collection. We conducted a total of 46 in-depth interviews with caregivers (33) and grandmothers (13) of targeted children. We observed 23 households to understand caregivers’ real-life experiences of child-feeding practices. Each observer spent a full day with a caregiver and her children—walked alongside them, observed them, and talked to them about their child-feeding practices. The observed issues were then recorded in a semistructured observation checklist. We also conducted 7 FGDs with fathers of under-5 children and at least 1 from each study sites. All interviews were recorded using a digital recorder. We developed a flexible semistructured guide and used it for similar participant groups. The guide allowed the data collectors to probe on areas of interest related to the research questions and objectives. Interviews were conducted in Bengali. Although there are some differences in the Bengali dialects spoken by interviewers and by participants, these differences were minor and did not inhibit communication or understanding.

Data Analysis

We performed thematic analysis strategies for analyzing data. The first 2 authors began to analyze the data in the initial stage of data collection in the field, which improved the quality of ongoing data collection. Transcriptions in Bengali were prepared immediately after the completion of each interview, then were read carefully, and coded. Data display and reduction was conducted after data collection was completed. Even during data display and reduction, the researchers backtracked to refine codes, reread texts, and revise some aspects of thematic data analysis. Once these tasks were performed, the main themes were finalized and each theme was examined fully and separately using the available data. The themes were then cross-checked to generate new insights for further exploration. The person who had collected the data at the community level analyzed the data with the PI of the study (H.S.). The first 2 authors (H.S. and M.F.U) analyzed the findings for this article. The second author (M.F.U.) collected the data and drafted the manuscript with the guidance of the PI. The third author (C.H.) reviewed the analysis and commented on the manuscript. The fourth author (T.A.) provided the overall guidance to the study.

The data were analyzed using Atlas ti (v.6.2) software, and the results were summarized and presented according to the objectives of the study. Some data were presented verbatim to demonstrate the diversity of views and ideas. Methodological triangulation of data from similar themes was used to ensure quality and facilitate validation of findings through cross verification from in-depth interviews, FGDs, and household observations. This helped us to create a more comprehensive and well-developed account of information. Since the study was conducted with the help of and within the settings of BRAC’s nutrition intervention programs, the initial themes were shared with BRAC’s program personnel to understand whether these themes and findings were accurate and on par with what have been observed in the field over the lifetime of their program. We analyzed data from caregivers, grandmothers, and fathers, and within each of these 3 participant groups, we identified common themes. We then identified common themes across the 3 participant groups. Finally, we summarized the results in accordance with the study objectives.

Results

Sociodemographic Characteristics

We interviewed a total of 33 caregivers, from across 4 types of users (eg, regular, irregular, ever, and never users). We interviewed 9 regular users, 7 irregular users, 11 ever users, and 6 never users. Most of the caregivers (28 of 33) and grandmothers (11 of 13) were from rural areas, and all the caregivers were women. The average age of the caregivers and the grandmothers were 40 and 59 years, respectively. The average age of children was 28 months. Eighteen caregivers were illiterate, 9 could only sign their names, 5 had primary-level and 1 had secondary-level education, and none had greater than secondary level of education. Eleven grandmothers were illiterate and 2 could only sign their names. In terms of occupation, a total of 21 caregivers were housewives, 8 were household domestic helpers, 3 were tutors, and 1 worked in the garments factory. Fathers were involved in day labor, as small-scale farmers, electricians, garment workers, migrant workers to the high-income countries, small businessmen, masons, religious leaders (hujur), service holders, and tailors. All grandmothers were dependent on the household head or father of the targeted children.

Trials and Experiential Influences: To Feed or Not to Feed Pushtikona

Both the regular and irregular use caregivers who fed Pushtikona to their children bought very limited number of sachets (1-3) on a trial basis for the first time, and they only decided to buy it for the second time if they had experienced that it increased the child’s appetite, if the child remained jolly and healthy, if the child played during illness, and if it did not lead to any health risks after feeding it. Caregivers’ attitudes became negative after they failed to observe any positive changes in their child after feeding Pushtikona, and, consequently, they decided to stop feeding it to their child. A caregiver in Balaganj said:

I stopped feeding Pushtikona to my child because I did not find any positive result after feeding it. My child still had no appetite for food nor did I find any changes in terms of physical growth.

However, our study found that if caregivers observed no negative health consequences and saw positive results during the first try, they decided to repurchase the product and feed it regularly to their children. Moreover, we found that caregivers were inspired to choose Pushtikona when they observed their neighbors feeding their children Pushtikona and heard those caregivers’ positive experiences. Caregivers were also motivated to feed Pushtikona when they heard health workers promoting Pushtikona to their neighbors.

Increased Appetite: Optimism Despite Financial Implications

Caregivers, in our study, were motivated to feed Pushtikona when they observed their children’s appetite increase after having eaten food fortified with Pushtikona. They did not see the increased appetite as a challenge or as an undue financial burden, since they had purchased it in the hope of increasing their child’s appetite. Although they were poor, had few sources of income, and faced difficulties to purchase regular family food items, they were dedicated to fulfilling their child’s increased demand for food somehow. One caregiver from Ulipur Upazila stated:

I have a piggy bank where I regularly try to keep very small amounts of money, like coins whenever possible and after 1 or 2 months, I buy Pushtikona for my child as I feel it increases my child’s appetite.

Taste and Appearance Affecting Willingness to Use Pushtikona

During the interviews, caregivers mentioned that their children do not like or want to eat food fortified with Pushtikona. The children in our study disliked the taste of the product and could easily recognize the difference in the flavor of the food with which it was mixed. Moreover, older children were more likely to refuse food fortified with Pushtikona. We observed that children preferred to eat it directly without mixing it in anything, as the whitish color of the product made it resemble the locally available and widely used powered milk, which the children also take directly in powder form. Consuming milk in powder form is a very common practice among children from poor households in both rural and urban areas, therefore the children could relate to it. Children refused food mixed with Pushtikona because of its dusty, salty, and overall unpleasant taste that discouraged caregivers from giving it to their children. Caregivers used various strategies to encourage their children to take Pushtikona. They mixed Pushtikona with small amounts of food and tried to feed the remaining amount of food after the child had eaten the portion mixed with Pushtikona. They also realized that if they mixed the powder in front of their child then the child would be unwilling to eat the meal. Therefore, they mixed the powder with the food while out of the child’s sight. The caregivers even choose their child’s favorite foods or mixed the product into sweets they knew the child would eat. However, when the grandmothers observed that their grandchildren disliked the taste of Pushtikona, they instructed the caregivers of the children to avoid mixing Pushtikona into food and told them to give other foods during feedings.

Side Effects of Using Pushtikona

In our study, caregivers were upset if their children’s stools were black, even though they did not necessarily feel that it was a direct result of feeding a child Pushtikona. Sometimes caregivers stopped feeding their child Pushtikona if they felt it resulted in vomiting or loose stools. As one caregiver of Monirampur reported:

I stopped feeding my child with Pushtikona when he had a reaction to the excessive amount of nutrition it contained, causing him to suffer from diarrhea.

However, our observation also found poor hygiene practices within these communities. In Satkania and Balaganj, we observed that when family members sat down together for a meal, they washed their hands without soap before eating. We also observed that feeding utensils were not cleaned with soap or other detergents and the children’s hands were not washed prior to eating or being fed. We also observed that caregivers did not wash their hands with soap after cleaning their children’s feces. The family members remained unperturbed and took their food without hesitation. We observed 1 child who had loose stools at the same time that she was being fed Pushtikona.

Inappropriate Initiation of Complementary Foods

The beliefs of caregivers and other household members, and religious views, play an important role in the timing of initiation of complementary feeding. A caregiver from Balaganj stated:

I knew about Pushtikona, but I was unable to start timely initiation of complementary foods, because my child was unwilling to take any family foods before the age of 12 months.

Grandmothers also expressed that complementary foods should be started when mothers were unable to produce sufficient milk.

Health Worker Visits and Purchase of Pushtikona

Caregivers reported that BRAC health workers never visited them and instead they had to purchase Pushtikona from the local market through the assistance of male members of their households. Caregivers were unable to get Pushtikona when the men in their household were too busy with income-generating activities, since it is socially unacceptable for the female caregivers to go to markets in rural regions and they can rarely leave their homes. Because of this constraint, they preferred to purchase the product from home. Therefore, if health workers never visited or visited only occasionally, caregivers’ use of Pushtikona was irregular or they never started. As the caregivers only purchased a few sachets to try before committing to purchasing a whole box, and due to failure of the BRAC health worker subsequently returning with a full box with 1 or 2 months of supply, the caregivers were unable to continue Pushtikona use. One caregiver said:

After feeding a few sachets of Pushtikona to my child, I could not continue the practice because the health worker did not visit my household anymore.

We found that the health workers visited their own neighbors’ households formally more than once in a month and also interacted more often with them during informal visits. Caregivers from these neighboring households could easily approach or communicate with the health workers to purchase Pushtikona. Because of these closer interpersonal relationships and easy access, caregivers who lived near a health worker could negotiate a lower price for Pushtikona when compared to caregivers who lived farther away from a health worker.

Miscommunication, Distrust, and Misperceptions About BRAC’s Services

Irregular and never use caregivers stated that BRAC’s health workers visited less and sometimes never counseled them about Pushtikona during household visits but provided various other information instead. Caregivers we spoke with who had never heard about Pushtikona were able to talk about other child health–related services of BRAC (eg, early initiation of breast-feeding, counseling about exclusive breast-feeding, demonstration of breast-feeding, and complementary feeding). The caregivers who were counseled about Pushtikona and often visited by health workers stated that most of these visits focused on counseling about the other health-related services of BRAC, and as a result, caregivers could not state or remember the benefits of Pushtikona. Irregular and never use caregivers felt that health workers were being untruthful in hopes of making a sale, and therefore they could never trust the benefits of Pushtikona enough to purchase the product. Caregivers were hesitant about the feeding practices of Pushtikona because they were confused by the inconsistent instructions that different BRAC workers gave. For example, one caregiver stated that the supervisor of a health worker (Shasthya Kormi) suggested to mix Pushtikona with semisolid foods, while the health worker (Shasthya Shebika) suggested she mix it into liquid food items. In terms of the price of Pushtikona, although BRAC gave a fixed price to their health workers, our findings showed that they were selling Pushtikona with different prices, which made caregivers distrustful of the BRAC community workers. Caregivers who lived near the SSs’ household, or were related to the SS, had purchased Pushtikona at a price less than BDT 2.5 (US$0.03) per sachet. On the other hand, a caregiver who lived far away from the SS’s home and had less regular interaction with the SS had purchased Pushtikona at a price higher than or equal to BDT 2.5 (US$0.03) per sachet. One caregiver from Ulipur Upazila said:

Shasthya Shebikas charged me more money compared to what she charged another woman I know who is a close neighbor of hers. I will ask her why she took more money from me. If she continues doing this, I will stop purchasing Pushtikona from her.

Shortage of supply and availability of health workers influenced the use of Pushtikona. The irregular use caregivers saved a small amount of money from their regular expenditures to purchase Pushtikona. Health workers were unable to provide the demanded Pustikona to those who either were able to lend money from neighbors or had the ability to pay in advance for Pushtikona. Caregivers felt they could not rely on the services of health workers due to their irregular delivery of Pushtikona. They felt that the health workers were lying to the caregivers about the shortage of supply so that they could sell the product at a higher price to other people. This situation also pushed the caregivers to discontinue Pushtikona feeding practices.

As one caregiver of Ulipur reported:

The Shasthya Shebika gave me only 5 packets (5 sachets) whereas I always bought 1 box (30 sachets). So I asked her about this and she replied that she did not have enough boxes at that moment, but I think she was lying.

Another caregiver of Balaganj stated:

After feeding a few sachets of Pushtikona to my child, I could not continue the practice as the health worker did not visit me and therefore I could not purchase the product.

The Cultural Preference for Junk Food

The caregivers who were ever and never users said they were unable to purchase Pushtikona, though in these households children aged 6 to 59 months were observed eating different types of junk foods. These junk foods cost more than Pushtikona costs. Caregivers who were irregular and ever users fed their children junk foods if the child was unwilling or refused to eat food mixed with Pushtikona or any other family foods. These caregivers had fed their children junk foods as immediate food solutions to reduce their children’s appetites. In this regard, a caregiver said:

If my child does not want to take rice, I have to buy various types of food from the bazaar to satiate her hunger. I give foods she likes, such as biscuits, chips, pickles, pie, etc, even though I do not know what kind of nutrition is present in these foods.

Economic Challenges for Unemployed Caregivers

Caregivers in the urban slums were involved in income-generating activities and were financially independent. However, most of the rural caregivers were highly dependent on their husband’s income, because they had no source of income under their control. For rural caregivers, it was often not possible to purchase Pushtikona without their husbands’ financial assistance. However, some caregivers from rural areas purchased Pushtikona without any assistance from the children’s father, by partaking in livelihood activities or by saving money from household expenditures. A caregiver from Monirampur stated:

As it will enhance my child’s brain and strength, I try to save money to buy Pushtikona from BRAC’s Shastya Shebikas, even though I myself am not involved in any income-generating activities.

Livelihood Restraints on Employed Caregivers

Agriculture is the main source of livelihood in rural areas of Bangladesh. The caregivers in rural areas said that they could not properly feed their children Pushtikona during the period of paddy husking because their household was too occupied with seasonal household chores. Similarly, caregivers from urban slums were engaged in different income-generation activities (eg, garment work, housework) and most of them went to their place of work early in the mornings and came back late in the evenings. Responsibility of feeding the children fell to elderly caregivers who could not provide adequate concentration toward the task, as they were not adequately informed about the Pushtikona.

A caregiver from an urban slum said:

I do not stay in the house because I have to go to the garment factories for work, leaving the children at home. Therefore, this (Pushtikona) is an extra burden for me and I cannot maintain the regularity of feeding Pushtikona.

Maternal Efforts Despite Family Constraints

The regular use caregivers expressed that if the health worker failed to provide Pushtikona, they purchased it from local markets. However, irregular and never use caregivers stated that they did not get any support from their husbands in terms of making decisions and receiving financial support. These types of caregivers tried to convince their husbands of the benefits but most failed, even after telling their husband to consult with doctors to better understand about Pushtikona. The fathers in this study stated that they had heard about Pushtikona from their wives but had never heard about it from any other reliable sources, and they were not confident enough about the benefits of the product. Therefore, they discouraged their wives from purchasing it. Grandmothers were also found to be a hindrance in accepting Pushtikona, as they played an important role in household decision-making. They discouraged caregivers from purchasing it is, as they believed that Pushtikona was not necessary for their young grandchildren. One grandmother from Satkania Upazila said:

I have had a number of boys and girls, but none of them were fed Pushtikona. Are they not grown up? They are in good health. So Pushtikona is not necessary for my grandson.

Discussion

Our study had similar results to previous studies from other places on caregivers’ use of MNPs, and our study also contributes some unique findings to the literature. Caregivers’ experiential usages on Pushtikona and responses from neighbors were influential for caregivers’ consistent purchase and feeding of Pushtikona. Similarly, a study of MNP usage from Western Kenya reported that caregivers first provided half of a sachet to their children to check for any adverse effects before feeling comfortable enough to feed their children the entire sachet. ¹⁴ Caregivers in our study stated that they fed their children a full sachet of Pushtikona, even during trials. Other studies found that acceptance of MNP was high in the refugee camps of Nepal because caregivers observed positive changes in children’s health and energy levels, ¹⁵ whereas, in Indonesia, acceptance of MNP was low because its instructions for use were unclear to caregivers. ¹⁶ Our study found that caregivers were more dependent on their own experiences with using the Pushtikona at home rather than on what the health workers told them. Caregivers in our study were clear about the instructions, but they were cautious about MNP’s benefits.

Micronutrient powder is distributed free of cost in many interventions targeting the poor and ultra-poor, ^11,17,18 and the additional cost burden arising from children’s increased appetite and food consumption after consuming MNP is a stress on household finances and a major concern for caregivers. ^14,17,19 However, caregivers from our study were not concerned about how they would be able to provide food to their children whose appetites had increased, though food is not always readily available to these underprivileged families.

Similar to the findings from previous research, we found that children fed foods mixed with Pushtikona are influenced by the color of the MNP product. The MNP was acceptable to the targeted children because of its white powdery contents that looked like the locally available sugar. ¹⁴ On the other hand, some of the children in the study preferred to eat the Pushtikona “straight,” without mixing it with food, because it looked to them like locally available powdered milk.

Caregivers in one study reported observing changes in the color of food after mixing MNP into it, and a few also reported that the texture, smell, and taste of the food were affected,^18,20 which caregivers in our study did not report. Unlike other studies, which have not commented on child age–related acceptability of MNPs, we found that older children refused MNP-fortified foods more than younger children did. Another contribution to the literature from our study is an understanding of the strategies that caregivers use to encourage their children to eat foods fortified with Pushtikona.

We found similar results on the side effects of Pushtikona as previous studies have found, where a few caregivers experienced negative side effects, mainly vomiting and black stools. ^7,18,20,21 In other studies, caregivers were informed that dark stools were merely a sign that Sprinkles was working and therefore they anticipated and were not alarmed by the change in stools’ color. ^14,22 Some families in a study in Haiti reported that preexisting health problems, such as vomiting, resolved themselves after using Sprinkles. ¹⁴ Other side effects observed upon using MNPs included loose stools and headaches.^18,19,20 Caregivers in our study reported seeing loose and black stools but did not report the side effect of MNP. As mentioned earlier in the results, inadequate hygiene practices may contribute to the observed incidence of loose stool after being fed MNP. In some areas of Bangladesh, less than 3% of mothers wash their hands with soap the time before preparing food and before feeding their children, ^23,24 and incidence of diarrhea was higher in those areas. ²³ The WHO recommends initiating complementary feeding from the age of 6 months, and introducing complementary foods fortified with MNPs after 6 months of age may have an impact on child nutrition. ²⁵ Like our study, previous research has also found that delayed initiation of complementary feeding was attributed to adequate breast milk supply. ⁴ Because some older family members hold this belief about adequate breast milk supply, some caregivers were unable to start feeding their children Pushtikona. To some extent, knowledge of HF with MNP varied among program beneficiaries, and the lack of knowledge created barriers toward receiving MNP, optimal usage, and compliance of MNP.^{12, 14,17,22,20,26} Our study found that caregivers could not purchase Pushtikona because other family members were unfamiliar with Pushtikona. Our study also investigated children’s consumption of junk food and its effects on usages of Pushtikona.

Caregivers expressed their willingness to manage their money so as to be able to purchase Pushtikona for their child, even though most of them had no direct income. In contrast, in Niger, fathers usually provided money for the purchase of MNP, but if the fathers did not have money, many caregivers could not afford MNP because they did not have any other form of income. ¹⁹

Our study found that most fathers were unaware of Pushtikona, and those who did know about it were confused about its benefits, despite their acknowledged importance as influential family members. In Kenya, grandmothers, fathers, older family members, and neighbors were all influential persons in making decisions regarding child-feeding practices. ¹⁷ Another study found that fathers did not know what the benefits of MNP were, and so they were doubtful of the ingredients in the product, sometimes inquiring whether the product was made with wood, stone, or whether it was mixed with poison or medicine. ¹⁷ Thereby, thinking the product was unsuitable for their children, ¹⁶ there was little willingness from the fathers to purchase and use Pushtikona. However, a study in East Timor found the reverse: The acceptability, intake, and willingness to continue using MNP was better when the child’s aunts and older siblings were aware and supportive of using it and helped caregiver in the preparation and feeding of food mixed with MNP. ²¹

Limitations and Strengths of This Study

The limitation we faced is that some of our thematic findings came from a single method of data collection and were not triangulated by data from other methods. We had limited time to study each process involved in HF with MNP and were therefore unable to examine interactions between caregivers/beneficiaries and health workers, as we had hoped to do. Data collectors were unable to observe caregivers’ exchanges with health workers directly so had to rely on the caregivers’ perspectives on these exchanges, which likely introduced some respondent bias. Another limitation of the study is that data were not collected from the service providers of BRAC on child feeding practices of caregivers; the providers might have provided additional insight for our analysis.

Despite these limitations, the study has a number of strengths, one of which is the use of multiple data collection techniques, including in-depth interviews, FGDs, and observations, to explore diverse information from various perspectives and to permit triangulation of findings from different angles. Hence, we feel that this study fills a gap in the literature on MNPs since this is the first qualitative assessment that identifies factors that influence HF with MNPs at the beneficiary level in Bangladesh.

Conclusions and Recommendations

We found that caregivers’ attitudes toward HF with MNP depend on their knowledge, personal experiments, and experiences, which in turn motivate them toward or against the purchase and use of Pushtikona to improve their child’s health. Caregivers felt positive about continuing the use of Pushtikona when it increased their children’s appetites and felt negative when they did not see or experience any of the desired benefits of the product. Caregivers are quite creative and experimental in their use of Pushtikona. They use different strategies to successfully feed it to their children, and when confronted with some reluctance on the part of their children, most caregivers persist in fortifying their child’s diet with Pushtikona. Future research could use an approach informed by diffusion of innovations, and/or stages of change (transtheoretical model) to characterize never, ever, and irregular users of Pushtikona and to identify appropriate strategies for moving these segments of the target audience toward regular use. ^27,28

Health workers should provide adequate counseling to caregivers who are experimenting with using Pushtikona and desire immediate physical improvement after feeding the product. In our observations, we found that caregivers were not focusing sufficiently on food quality and dietary diversity while feeding their children, even though they were not involved in other households activities at the time. Counseling should focus on increasing caregivers’ prioritization of proper child feeding practices. Caregivers who forget to restart the feeding of Pushtikona, after their child recovers from an illness, should be counseled more often through frequent and regular household visits by BRAC health workers. Counseling should be extended to other family members, especially fathers, as they are often influential in the purchase and usage of Pushtikona.

Counseling on Pushtikona should be mandatory and health workers should improve the regularity of their visits. Health workers should conduct follow-up activities related to child feeding practices with Pushtikona, thereby ensuring timely supply of the product and better understanding about the consistency of caregivers’ practices. Health workers should provide the accurate recommended messages on the usages of Pushtikona, and if the caregivers in a locality followed the incorrect practices, health workers should counsel them repeatedly as there are only a few households with children under 5 in their designated area. Health workers should strive to deliver their messages to the whole community so as to reduce confusion about Pushtikona. Prices of Pushtikona should be the same for all caregivers of beneficiary children so as to avoid other challenges and distrust. Prices of Pushtikona were closely associated with caregivers’ financial ability, and the relationships with health workers influenced the purchase of the product. We found misconceptions and distrust among caregivers due to inadequate counseling, shortage of supply, and irregular household visits by health workers. In some cases, caregivers became confused when they heard about different feeding practices for Pushtikona from different health workers. In addition, caregivers who had better interaction with health workers were more regular with their use of Pushtikona.

This study highlights the importance of understanding cultural perceptions of the MNP intervention program, particularly the need to identify a locally appropriate intervention strategy that resonates with the community and encourages adoption and use of the product. We recommend prioritizing providing explicit instructions about how to use Pushtikona and what to expect from it at enrollment so as to alleviate misconceptions and increase the chances of acceptance of proper utilization. ¹⁶ Factors related to demand, purchase, and utilization require attention before and during implementation. Formative research on the existing knowledge, perceptions, attitudes, motivations, and practices should be considered for further successful design and implementation of interventions related to HF with MNP. This study suggests that improved service delivery mechanisms could increase the demand for and improve the practice of HF with MNP at the community level. The findings of this study will help with course corrections of the interventions of HF with Pushtikona program.