Process Evaluation of a Large-Scale Community-Based Nutrition Program in Malawi

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.