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Acceptability and feasibility of a child-feeding toolkit in Malawi

By Ellah Kedera, Meghan Anson, Emily Faerber, Jennifer Weiss and Amy Webb GirardFeeding bowl and slotted spoon

The authors acknowledge and thank all stakeholders involved in supporting the research highlighted in this article, particularly the Department of Nutrition, HIV and AIDS, Malawi  and the World Bank. Special thanks to Concern Worldwide’s Health and Nutrition team in the Mchinji District and the study participants for their time and collaboration.

Location: Malawi

What we know: Dietary quality and fortification or supplementation is the typical focus of behaviour-change communication around complementary feeding; portion size and food consistency receives less attention.

What this article adds: In collaboration with the Government of the Republic of Malawi and Emory University, Concern Worldwide evaluated infant and young child feeding practices and the feasibility, acceptability and cultural appropriateness of a practical feeding toolkit to improve complementary feeding practices in the Mchinji District. Key informants identified the need for cues in complementary feeding volume, frequency and consistency. The toolkit was well-received. Findings have informed operations research to evaluate and quantify the effectiveness of the toolkit in improving complementary feeding practices (the results are due in September 2016).


In the Mchinji District of Malawi, 53.7% of children under the age of five are stunted, 13.1% are underweight and 3.3% are wasted (National Statistical Office and ICF Macro, 2011); rates exceed national averages and are among the highest in the country. Efforts around child nutrition have failed to meaningfully reduce rates of stunting in Malawi (Scaling Up Nutrition, 2011). The World Bank-funded, government-led, Nutrition, HIV and AIDS Project (NHAP) aims to contribute to a reduction in child stunting and maternal and child anaemia and prevent transmission of HIV and AIDS. This project includes a ‘Support to Nutrition Improvement Component (SNIC)’ that aims to enhance and scale up maternal and child nutrition service delivery at community level and strengthen sector policy and programme development, management and coordination at central, district and community levels. Concern Worldwide is the SNIC non-governmental organisation (NGO) implementing partner in the Mchinji District, one of 15 SNIC districts in Malawi.

As part of the SNIC project in Mchinji and in collaboration with Malawi’s Department of Nutrition, HIV and AIDS and Emory University, Rollins School of Public Health, Concern Worldwide is conducting operations research to evaluate the effectiveness of a feeding toolkit (demarcated feeding bowl, slotted spoon and counselling card) to improve complementary feeding practices among families with children aged six to 23 months in three target traditional authorities (TAs): Zulu, Mduwa, and Mkanda. The toolkit was designed by a team of students and faculty from Rollins School of Public Health and the Georgia Institute of Technology. Previous testing in India and Kenya indicated the toolkit was acceptable and had the potential to shift dietary practices (Collison et al, 2015), (Kram et al 2015). As part of the larger research goal, formative research was conducted to evaluate current infant and young child feeding (IYCF) practices in the Mchinji District and to assess the acceptability and feasibility of the feeding toolkit to enhance complementary feeding of children aged six to 23 months, including potential barriers to use and optimal delivery platforms. Key findings are summarised here.

Box 1: Feeding toolkit

The toolkit comprises a demarcated feeding bowl, slotted spoon and counselling card. The bowl is designed with symbols and demarcations to denote recommended meal frequencies and quantities of food for children at 6-8 months, 9-11 months, and 12-23 months. Symbols and demarcations on the bowl also cue the extra food recommended for women during pregnancy and lactation. The slotted spoon guides caregivers in preparing complementary food of appropriate consistency. A pictorial counselling card provides pictorial instructions on how to use the toolkit to achieve recommended dietary practices, handwashing practices and dietary diversity. It is suitable for caregivers with low literacy.


This cross-sectional, qualitative study was conducted from July-August 2015 through focus group discussions (FGDs) in two TAs, one peri-urban and one rural. Participants comprised the following target groups:

FGD guides were developed for each target group and translated into Chichewa. Topics included beliefs and current practices related to maternal nutrition, IYCF, influencers of maternal and child nutrition, perceived benefits and challenges of the feeding toolkit and potential delivery platforms. Ten FGDs were conducted, one with each target group in each TA. The number of participants in each focus group discussion ranged from four to 15. A total of 103 individuals – 63 females and 40 males – participated in the study.


Key findings regarding IYCF practices were:

In terms of feedback on the toolkit:


Programmatic recommendations include community sensitisation prior to roll-out; development of a feeding toolkit training guide for programme staff, community health promoters and lead mothers; and formulation of follow-up mechanisms within programmes to ensure proper use of the toolkit. The feeding toolkit should be deployed in conjunction with programmes or interventions aimed at improving household food security. Grandmothers, mothers-in-law and husbands should be targeted as part of behaviour-change programmes.

These findings have informed the ongoing operations research to evaluate and quantify the effectiveness of the feeding toolkit to improve complementary feeding practices.  Results from the Mchinji District Feeding Bowl Trial will be available in September 2016.

For additional information, please contact Meghan Anson



Collison D.K., Kekre P., Verma P., Melgen S., Kram N., Colton J., Blount W. & Webb Girard A., 2015. The acceptability and utility of an innovative feeding toolkit to improve maternal and child diet practices in Bihar, India. Food and Nutrition Bulletin. pp24-32.

Kram N., Melgen S., Kedera E., Collison D.K., Colton J., Blount W., Grant F. & Webb Girard A., 2015. The acceptability of dietary tools to improve maternal and child nutrition in Western Kenya. Public Health Nutrition, pp1-11.

National Statistical Office and ICF Macro, 2011. Malawi Demographic and Health Survey 2010. Zomba, Malawi, and Calverton, Maryland, USA: NSO and ICF Macro.

Scaling Up Nutrition, 2011. SUN 1000 Special Days 2011-2016, National Education and Communication Strategy for Prevening Child Stunting in Malawi. Lilongwe 3: The Government of Malawi; Office of the President and Cabinet, Department of Nutrition, HIV, and AIDS.


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Ellah Kedera, Meghan Anson, Emily Faerber, Jennifer Weiss and Amy Webb Girard (). Acceptability and feasibility of a child-feeding toolkit in Malawi. Field Exchange 52, June 2016. p24.



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