Formative Research to Tailor Maternal Nutrition Services Introducing Multiple Micronutrient Supplements (MMS) for Pregnant Women in Rural Madagascar

OBJECTIVES: To develop tailored social marketing approaches for introducing multiple micronutrient supplements (MMS) to pregnant women in rural Madagascar. METHODS: Design. This formative study utilized a Rapid Assessment Procedures approach conducted over two iterative phases in Itasy and Vatovavy Fitovinany, Madagascar from October 2020 – March 2021. Data collection and sampling.Phase 1 utilized community workshops, focus groups, and market observations to generate community inputs for developing culturally appropriate and tailored MMS programming. Phase 2 included free lists and semi-structured interviews among pregnant women and health workers for an ethnographic understanding of pregnancy-related practices in this setting. Analysis. Textual data from interviews were thematically analyzed using Dedoose software. Numerical data from market observations and community workshops were summarized using descriptive statistics. Findings were grounded in a social marketing framework and triangulated across methods and participant types to enhance data credibility. RESULTS: Formative findings can be conceptualized using the ‘4ps’ of social marketing: Product. In this setting, women voted for an orange-colored MMS box design because the color reflects locally-available fruits such as mangoes and oranges. Red and white colors were secondary preferences. Price. Pregnant women explained some willingness to pay for MMS, suggesting that 500 to 600 Ar/30-day supply may be appropriate, but emphasizing the need for free provision to increase coverage among more vulnerable groups. Placement. Distributing MMS using a combination of both facility-based and community-based approaches was suggested by participants for ensuring optimal program coverage and reach. Promotion. Pregnant women suggested the need for community-based, interpersonal communications using health agents and health workers as the primary communication channels to promote MMS compliance. Several local language (Malagasy) phrases were generated through participatory workshops to promote MMS specifically to pregnant women in this setting. CONCLUSIONS: Participatory formative research in rural Madagascar provided context-specific, social marketing inputs that may help improve MMS acceptability and compliance in Madagascar. FUNDING SOURCES: Sight and Life Foundation.