Mothers' Perceptions of Child Nutrition and Growth Monitoring: Insights and Challenges within Rwanda's National Nutrition Program.

doi:10.21203/rs.3.rs-5194894/v1

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Mothers' Perceptions of Child Nutrition and Growth Monitoring: Insights and Challenges within Rwanda's National Nutrition Program.

https://doi.org/10.21203/rs.3.rs-5194894/v1

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Introduction: Many Rwandan children under the age of two suffer from malnutrition, which affects their physical growth and cognitive development. This study explored the perspectives and attitudes of mothers of children eligible for child growth and nutrition monitoring services to find out how attendance of such services and adherence to treatment may be improved.

Methods: We conducted fifty-two in-depth interviews with purposively sampled mothers of infants below 2 years. The interview guide was developed based on the health belief model. Through deductive thematic analysis, we explored the mothers' perspectives, attitudes towards the program, including perceived strengths and challenges and factors influencing attendance.

Findings: Mothers acknowledged the adverse effects of undernutrition on children’s health. They appreciated the child nutrition services, including nutrition education and food supplementation. In addition, they recognized the contributions of community health workers (CHWs) in conducting home visits and providing education and support for child nutrition. However, they encountered challenges such as long waiting times at health centers which interfered with their caregiving responsibilities and activities to make an income, and stigma associated with seeking treatment for undernutrition.

Conclusion: Poverty was a major barrier to child nutrition service use, despite incentives being provided to the poorest families. Outreach programs, integration of child health services and efforts to reduce the stigma associated with seeking help for undernutrition may improve the utilization of nutrition services and adherence to nutritional advice.

Nutrition & Dietetics

Mothers

child nutrition

Growth monitoring

implementation barriers

Health Belief Model

During childhood, malnutrition, repeated infections, and limited psycho-social engagement can impede normal brain and body development (1, 2). Estimates indicate that this affects as many as 250 million children globally (3). The Lancet series on Early Childhood Development highlights the vital role of appropriate nutrition and growth monitoring to detect deviations from expected growth patterns and provide timely interventions, when needed, to enhance child health outcomes and save lives (4).

In Rwanda, child malnutrition is still a significant challenge (5–7). Despite progress made over the last three decades, the government still faces difficulties in comprehensively addressing the issue of malnutrition. The national prevalence of stunting in children under 5 years decreased from 38% in 2015 to 33% in 2020 (8, 9), but falls short of both national and global targets, and exceeds the 2020 African regional average of 30.7% (11). There are also within-country variations in the malnutrition prevalence, with the highest levels of stunting reported in the North (40.5%) and West (40.2%) provinces. This variation is attributed to food insecurity and lack of implementation of nutritional interventions aimed at reducing undernutrition challenges within these respective settings.

Nutritional assessments are integral components of monthly outreach meetings at the village level organized by community health workers (CHWs), and are also included as part of scheduled immunization visits at the health center for children under two years old and in the Integrated Management of Child Illnesses (IMCI) program to ensure consistent monitoring of children's nutritional well-being (10, 11). Data on child nutrition from outreach activities are compiled by CHW and reported monthly via the Health Management Information System (HMIS), supporting tracking of children's nutrition and facilitating interventions under the National Nutrition Program (NNP). Children with normal status receive routine monitoring, while those requiring further attention are referred to public primary health centers for detailed evaluation by nutritionists.

The Fortified Blended Foods (FBF) program, a core component of the NNP, specifically targets children from the poorest segments of the population and incentivizes mothers or caregivers to participate in monthly growth monitoring activities at primary health facilities by providing nutrient-rich supplements and modest financial incentives in the form of a quarterly monetary stipend to those that attend. As part of the FBF program requirements, health workers are also mandated to report essential undernutrition indicators regarding children's nutritional status in a timely manner (12, 13). This program has led to improved monitoring of child growth and nutrition management practices throughout Rwanda (14, 15). However, with growth monitoring coverage at around 75% (15), targeted interventions are needed for groups with lower coverage.

Barriers to the implementation of child nutrition programs in low- and middle-income countries (LMICs), and in Rwanda specifically, commonly include insufficient funding and personnel for nutrition programs, fragmentation within the health system and lack of qualified personnel. This may affect the perceived quality and benefits of the nutrition services. Concerns about the quality of services combined with limited accessibility resulting from long travel distances to healthcare facilities, lack of awareness among caregivers regarding the benefits of growth monitoring, and socioeconomic factors such as poverty and food insecurity may affect the attendance of monitoring sessions (16)(17)(18). Cultural influences on dietary habits may affect adherence to the counseling provided on child nutrition. Collectively, these barriers may hinder the effective utilization of services aimed at improving child nutrition and growth monitoring, ultimately impacting public health outcomes.

In this study, we aimed to explore the perspectives and attitudes regarding the nutrition program of mothers with children eligible for these services.

Study setting

Our study was carried out in Rwanda's public primary healthcare centers, which are responsible for most child nutrition-related issues (19). Interviews were conducted in three districts: Kirehe in the Eastern Province, Nyabihu in the Western Province, and Ruhango in the Southern Province (19). In Kirehe, childhood stunting decreased from 40.3% in 2015 to 29% in 2020, making it a “well performing” district regarding the national goal of reducing childhood stunting rates. Kirehe has 18 health centers and one district hospital, serving a population of 340,893 (21). In contrast, in Ruhango, an increase in childhood stunting from 20.8% in 2015 to 41.5% in 2020 has been reported, making it a “low performing” district. Ruhango has 304,390 residents served by 15 primary health centers and two district hospitals. Finally, in Nyabihu, with 295,580 inhabitants and 16 primary health centers and two district hospitals, the stunting rates were 59% in 2015 and 45% in 2020 (10, 11).

Rwanda's health system relies on approximately 59,000 CHWs who play a crucial role in remote areas, conducting monthly anthropometric measurements and collecting data on nutrition status and child growth (20, 21). Typically, three to four CHWs serve a village with 100–250 households. In practice, a single health center generally links to around 5 to 10 villages, coordinating the efforts of the CHWs. Among them, a female and male CHW form a specialized pair known as Binômes, responsible for child health and nutrition in their respective villages and reporting to the health center.

Data collection tools for conducting child nutritional assessments, along with free-of-charge phone numbers, facilitate communication and data transmission (22) among CHWs, caregivers (often mothers), and health centers. Ideally, each health center should have a dedicated nutritionist responsible for child health and nutrition; however, gaps persist in some centers where other health workers take on the nutritionist's role, delivering both healthcare services and overseeing child nutrition and growth monitoring.

Interview guide

We developed a semi-structured interview guide using the Health Belief Model (HBM) (26). The HBM consists of six constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, self-efficacy). Based on these constructs, the questions covered mothers’ perspectives on the benefits, challenges, and factors influencing their engagement in the NNP, particularly in growth monitoring activities. Additionally, we explored their views on measures to achieve universal coverage, on their child’s growth (on paper or via phone), perceived trustworthiness of nutrition services, and (see annexed supplementary file 1: “Interview guides with mothers” for more details). Interview guides were first developed in English and then translated into Kinyarwanda. We conducted three pilot sessions in the Nyabihu district to refine the interview guides.

Sampling and data collection process

We used purposive sampling to select three public primary healthcare centers based on their geographical location in each of the three districts to ensure diverse representation: one close to the district hospital, a second at an intermediate distance to capture average conditions, and a third that was remote. Within these centers, we recruited mothers attending child growth monitoring sessions. We conducted a total of 52 interviews; 32 mothers who regularly attended the sessions and 20 mothers categorized as "defaulters” due to frequent absenteeism. Face-to-face interviews were arranged either at the participants’ homes or at the health center. The interviews lasted approximately one hour, and audio recordings were made. Written consent was obtained from all participants. We assigned unique codes to the transcripts to maintain anonymity, and separately stored the informed consents forms.

The first author (ER), with a background in nutrition and health informatics, conducted the interviews in Kinyarwanda. Subsequently, a bilingual specialist translated and transcribed the recordings into English, which were then compared with the audio recordings by ER and TU to check that the original content was maintained. Data collection took place between April and December 2021. Reporting of data collection procedures follows the Consolidated Criteria for Reporting Qualitative Research (COREQ) recommendations (23).

Data analysis

Employing a deductive thematic analysis approach, we focused on the constructs of the Health Belief Model (Table 1).

In-depth interview transcripts were coded using predefined codes. We used NVivo 12 software (24) for data management and analysis.

Table 1

Thematic Data Analysis Process Using the HBM.
Themes	Codes
Perceived susceptibility and severity of the effects of undernutrition	Susceptibility to undernutrition
	Consequences of undernutrition
Perceived benefits of growth monitoring attendance	Benefits for FBF versus non-FBF beneficiaries
Perceived barriers to growth monitoring attendance	Care seeking and practical barriers
Perceived barriers to growth monitoring attendance	Societal and cultural barriers
Self-care knowledge, practice and family cooperation, self-efficacy	Mother’s self-care and family cooperation
	Decision-making on growth monitoring service utilization
Cues-to-action and reminder for attendance	Major Influencers for Attendance
	Contact person and time for communication
	Communication strategy
Other factors affecting coverage and service utilization	Availability of skilled staff
	Outreach programs
	Appointment reminders

TU and ER independently applied deductive coding using a predetermined codebook. Subsequently, they conducted a collaborative review, comparing and discussing the coded data to refine the code list. Any discrepancies were addressed, with intervention from two additional coauthors (EP and JFF), to reach consensus (25).

Description of the research team and stakeholder engagement

In the context of this study, stakeholder engagement at the outset with key entities such as the Ministry of Health, Rwanda Biomedical Centre, and the National Childhood Development Agency was prioritized to align research objectives with the national health priorities within Rwanda's nutrition program, and to select relevant research sites. We conducted three stakeholder engagement sessions in three study districts with central-level program managers and district supervisors of the national nutrition programs. Insights from stakeholders were used to plan strategic engagement with health center management and in the selection of the study population.

We interviewed 52 mothers between 18 and 32 years of age. In terms of educational background, 35 (67%) participants had received up to six years of formal education, while 17 (33%) had more than six years. The participants came from various family structures, including single mothers and those living in extended family settings with their husbands, and they had between four and seven children. In terms of economic status, 36 of the mothers were classified as beneficiaries of FBF, coming from low-income households, while 16 were from middle-income households and did not qualify for FBF assistance.

Perceived susceptibility and severity of the effects of undernutrition

Mothers recognized the risks and seriousness of undernutrition, and its potential negative impacts on their children. One mother expressed, “You know, in our village, we hear all kinds of stories. Every time I look at my child, my heart feels heavy... knowing that a lack of good nourishment could harm his future. Even with the challenges we face and the scarcity of money because of poverty, I work hard to provide him with nutritious meals. I want to make sure he has the chance to grow strong and healthy. I must admit, it’s not just my child; this is a troubling situation for many. There are people who have children often... without the money to care for them, which leads to a poor quality of life. It’s better to have a child that you can afford... and ensure they have a better life. This situation is truly distressing.” (A 38-year-old mother from Nyabihu District with an 18-month-old child and five other children at home).

Additionally, the interviewed mothers demonstrated an understanding of the immediate and long-term effects of malnutrition. They acknowledged that a weakened immune system could increase susceptibility to illnesses and lower energy levels, impacting daily activities. Concerns about persistent issues like stunted growth and cognitive barriers were prevalent among the mothers. According to a mother whose child had growth faltering and regularly attended the program: “Thanks to the nutritionists at the health center, I’ve realized how much malnutrition can change everything. I can already see it affecting my child. A simple illness today could lead to big problems for their education later on. Plus, all the time I spend at the center for treatments takes away from important work like farming, which we really need to support our family’s income.” (A 39-year-old mother from Ruhango District with a 12-month-old child and four other children at home).

Another mother from a middle-income family provided a contrasting perspective, highlighting the challenges she faces in prioritizing her child's nutrition. She expressed “I know how important a balanced diet is for my child's health... but sometimes it feels impossible to make nutrition a priority with everything I have to juggle. Between work and household chores, it’s hard to provide healthy meals consistently. My child is mostly cared for by the maid... and I only get to check on him in the evenings, which isn’t enough. There are times when I miss the growth monitoring at the health center because of work. Still, I completely understand the serious effects that undernutrition can have on him.” (A 40-year-old mother from Kirehe District with a 14-month-old child and three other children at home).

Some shared experiences from their community on the effects of undernutrition. For example, a mother narrated: “There was a child in our area who was severely malnourished... and needed nutrition rehabilitation at the health center. The mother and her child were part of the program, and it took months for them to recover. Learning that he could face developmental issues really hits home. It reminds me how important it is to make sure my child is eating well.” (A 27-year-old mother from Nyabihu District with a 2-year-old child and two other children at home).

In one rural district where stunting rates have been increasing, mothers expressed significant concern on the severity of malnutrition, largely attributing it to the challenges of climate change and ongoing food insecurity stemming from prolonged drought conditions in their areas. One mother reflected this by saying, “In our village, the seasons have changed. The rain that used to help our crops grow has become rare, and our fields are dry. We have a hard time growing enough food to feed our families... and I can see my child’s health suffering because of it. When the droughts last longer, it feels like hope is fading... and I worry that I can’t give my child the meals they need to grow strong and healthy.” (A 36-year-old mother from Ruhango District with a 14-month-old child and six other children at home).

Perceived benefits of attending child nutrition and growth monitoring programs

Participants expressed a commitment to support child nutrition and development and were aware of the importance of food supplements and nutrition education in addressing child nutrition needs. They expressed that engagement in growth monitoring sessions improved their understanding of child nutrition and growth, while the financial incentives were also supporting their child’s well-being. The provision of FBF and minimal financial incentives, garnered appreciation for its impact. One mother whose child is under the FBF program shared, “We’re grateful for the food we get from the FBF... it helps us prepare porridge for our children and improves their nutrition. I’ve seen my child’s health getting better, and even the little bit of money from government support helps us try to give them a better diet.” (A 22-year-old mother from Kirehe District with a 12-month-old child and one other child at home).

Mothers viewed the program’s food assistance as essential for economically disadvantaged households, easing mothers’ efforts to provide sufficient nutrition for their children. One mother illustrated this sentiment, saying: “I think poverty is the root cause of these problems. How can you find milk regularly? Even if you try, it’s hard to get milk every day. For example, I live alone and depend on a day job while also paying rent, which makes it tough to afford what my child needs. You know what? A liter of milk used to cost 300 Rwandan francs, but now it’s gone up to 400 francs. Sometimes, it’s impossible to come up with that much from a day’s earnings. Can you imagine? I took my child to the District Hospital, and they eventually transferred us here, where he gets porridge (FBF) and milk (pasteurized). Now there’s been a change; he is gaining weight. He is 9 months old and weighs 6.8 kg.” (A 39-year-old mother from Ruhango District with a 9-month-old child and two other children at home).

The FBF program was also supported by mothers who were not part of it: “I would say that the support given to vulnerable groups is helpful... some children are doing better than before. But I think they still need more... to ensure a balanced diet for their kids.” (A 33-year-old mother from Nyabihu District with a 19-month-old child and two other children at home.)

Some irregular attendees complained about being removed from the list of beneficiaries, resulting in the loss of this crucial support. A mother further elaborated: “As mothers, we really feel the impact of inconsistent financial incentives. When we miss a session, it not only affects our access to funds... but also makes it very hard for us to provide our children with a balanced diet. We often worry about how to feed our families... and make sure they grow up healthy. We need more support to help us overcome these challenges and take care of our children properly.” (A 37-year-old mother from Kirehe District with a 16-month-old child and seven other children at home).

All the interviewed mothers valued the frequent home visits by CHWs, with one remarking: “Even though I am determined to take care of my child's health... spending 4 to 6 hours waiting for services is really demanding and exhausting. Many of us have to travel almost an hour to reach the health center... only to find long queues with other parents who are also desperate for the same help. It can feel like we’re losing a whole day... which adds to our stress and anxiety. We often worry about our children’s needs while we wait... wondering if we could have done better if we had more timely access to care. It’s not just about the time; it’s about the energy we put in and the sacrifices we make to prioritize our children’s health. We really wish for better services... as we are trying our best for our families.” (A 30-year-old mother from Ruhango District with a 11-month-old child and three other children at home). This sentiment was echoed by many mothers, reflecting their trust and appreciation of the CHWs.

Perceived barriers to growth monitoring attendance

The most frequently mentioned barrier to growth monitoring attendance was long waiting times. Many participants described waiting for over 5 hours as gruelling, affecting their ability to access timely care. One mother benefiting from FBF expressed: “Even though I am determined to take care of my child's health... spending 4 to 6 hours waiting for services is really demanding and exhausting. Many of us have to travel almost an hour to reach the health center... only to find long queues with other parents who are also desperate for the same help. It can feel like we’re losing a whole day... which adds to our stress and anxiety. We often worry about our children’s needs while we wait... wondering if we could have done better if we had more timely access to care. It’s not just about the time; it’s about the energy we put in and the sacrifices we make to prioritize our children’s health. We really wish for better services... as we are trying our best for our families.” (A 40-year-old mother from Kirehe District with a 12-month-old child and four other children at home.)

An additional barrier was the perceived ineffectiveness. One mother stated: “I can get Fortified Blended Food (FBF), but sometimes it arrives late... and I have to go to my day job just to afford some porridge. Finding money for a good diet is really hard... as it can cost Rwf 200 to Rwf 600 in a single day. I also have to pay rent. If I can’t pay the rent on time... the landlord will evict me, making life even harder for me and my child... and then we face problems like stunting.” (A 39-year-old mother from Nyabihu District with a 12-month-old child and four other children at home).

Lack of respect from health workers was also mentioned as a disincentive to attending nutrition services. A mother who was not benefiting from the FBF program, but was eligible for attending growth monitoring, expressed “It just feels like a waste of time being at the health center for so long... without any real benefits. When we’re late... they’re harsh and send us back home, telling us to come back for the next visit. That’s really frustrating after all the effort to get there. For us, every visit is a challenge—we spend our time and energy, often juggling other responsibilities, only to leave feeling disappointed. We need a program that is more supportive... one that recognizes our needs as mothers and caregivers, and where we can truly feel the benefits of the services offered.” (A 30-year-old mother from Ruhango District with a 11-month-old child and three other children at home.)

Financial constraints and competing responsibilities were additional reported barriers, as they often influenced the decisions mothers made. Some discussed struggling to balance limited resources while caring for multiple children, where immediate needs often conflicted with their children's long-term well-being. Consequently, some chose livelihood activities to secure food for their children instead of attending growth monitoring visits. One mother shared: “We often find ourselves caught between our limited resources... and the needs of our children. With so many mouths to feed... the immediate need for food sometimes feels more important than our children's long-term well-being. Many of us take on hard work like farming... knowing it will secure meals for our families today, even if it means missing important growth monitoring visits. It’s a tough choice... but survival often makes us prioritize the present over the future.” (A 37-year-old mother from Kirehe District with a 16-month-old child and five other children at home).”

Moreover, the numerous services and appointments at health centers for various programs required significant involvement from mothers, often leaving them feeling overwhelmed, criticized, and judged regarding their parenting abilities. One mother described her situation, stating: “I go back every month for different programs... like child rehabilitation, FBF support, immunizations, monthly community screenings, and CHW home visits. These visits put me under unwanted scrutiny... and criticism, which makes me feel like I’m not taking care of my child properly.” (A 38-year-old mother from Ruhango District with a 10-month-old child and four other children at home).

Due to the fear of stigma some middle-income mothers expressed reluctance to regularly attend the nutrition program due to fear of being perceived negatively by their peers. One mother shared, “I try to avoid going to the health center too often... because I don’t want my neighbors to think I can’t provide for my child. They see these programs as something only for poor families... and it can be embarrassing to be linked to that. I usually go to the health center only during vaccination visits.” (A 29-year-old mother from the Kirehe District with a 15-month-old child and two other children).

Self-care knowledge, practice, and family support

Mothers reported blending traditional knowledge with modern health practices to improve self-care and family nutrition, emphasizing the vital role of family support. However, they encountered challenges, including resistance to new methods, stemming from cultural beliefs and differing views on family planning, which highlight the complexities of promoting health within the family context. Reflecting on the significance of self-care, mothers stressed how they integrate ancestral wisdom into their routines. One mother shared,

“I follow the teachings passed down from my mother and grandmother... along with the valuable lessons I've learned from community health workers and nutritionists during cooking demonstration sessions in my village. These traditions remind me of the strength and resilience of our women... while the new knowledge helps me take better care of not just my children... but also myself.” (A 31-year-old mother from Nyabihu District with a 10-month-old child and four other children at home.)

The discussion revealed the critical role of family support in implementing self-care and nutritional practices. During the discussions, the significance of family support was also highlighted. One mother recounted: “There was one day... when my husband joined the cooking demonstration session in our village. When we got home, he helped me with cooking. This really made a difference... especially in our Rwandan culture where men don't usually cook. His willingness to step into this role... not only lightened my workload but also created a feeling of partnership in our home. His involvement in meal prep brought us closer... allowing us to share the responsibilities and joys of cooking together. It truly reminded me that we are a team... committed to giving our children the best start in life.” (A 22-year-old mother from Kirehe District with a 12-month-old child and one other child at home.)

However, not all mothers experienced such support. Some faced resistance from family members due to conflicting cultural beliefs about child nutrition practices. One mother expressed, “You see... there are different views in our family... because of our cultural traditions. This leads to conflicting opinions on child nutrition practices. While I know how important balanced diets and new nutrition methods are... some family members stick to traditional beliefs that are really deep in our culture. Sometimes, this creates tension... because they may not see the benefits of the new practices I’ve learned. It’s frustrating... trying to bridge the gap between modern advice and traditional values. But I believe that... open conversations and small changes can help us find common ground. In the end, we all want what’s best for our children... and dealing with these differences is part of our journey towards a healthier family.” (A 43-year-old mother from Ruhango District with a 17-month-old child and seven other children at home.)

Additionally, another mother highlighted a specific challenge of differing views on family planning within her household: “While I try to attend all my appointments... and follow the advice I get, my husband is against family planning. It’s hard. Even though they talk about family planning during nutrition education sessions... to help prevent undernutrition—especially since I have seven children—finding a balance is getting tougher. I want to give my children the best... but with such different views at home, I often feel alone... and frustrated. It’s really hard to speak up for change in my family... when there’s pushback against the very things that could help us improve.” (A 35-year-old mother from Nyabihu District with a 17-month-old child and six other children at home.)

Cues-to-action, information, education and reminders

Mothers frequently mentioned that regular visits from CHWs, as part of the national outreach program, served as effective prompts for action. These visits provided personalized reminders and encouragement for mothers to participate in growth monitoring sessions and adhere to nutritional advice, which they had otherwise overlooked due to their busy schedules. Additionally, nutrition education sessions conducted by nutritionists during these visits equipped mothers with essential information about child nutrition, balanced diets, and healthy practices.

One mother conveyed, "The home visits by the CHWs... have been a real blessing for me and my family. They don’t just come to check on us... they talk about why nutrition is important. Their chats... really opened my eyes to how good food helps my child's growth and health. When they explain... how healthy food is better for my kids, I start to feel... more responsible for the choices I make every day. This help... shows me how these changes can help my child grow... and make a better future for our family. I’m very grateful for the knowledge... and support they give me... because it helps me take better care of my family... and make good choices for our health." (A 30-year-old mother from Kirehe District with an 11-month-old child and three other children at home.)

Mothers had diverse preferences for information and education channels. Some valued personal interactions with CHWs, finding face-to-face discussions to be the most valuable. One mother shared: “When the CHW talks to me... it makes me feel like I have to join the programs they offer. Their words really hit home, and I feel connected to what they say. It’s like they see me... understand what I’m going through... and truly care about my children’s well-being. When they speak to me face-to-face, it lights a fire in me. I realize I have a role in my children’s future.” (A 37-year-old mother from Ruhango District with a 17-month-old child and four other children at home.)

Other factors affecting health care service utilization

The lack of nutritionists in health centres emerged as a factor affecting health care service utilization in certain locations. A middle-income mother expressed her worries, saying: “Honestly... at our rural health centre, there is a clear need for more nutritional education and guidance. But... the absence of nutrition experts is a major challenge for us. We rely on the aid of social workers to address malnutrition, but... they may not have the specialized training needed to tackle this issue effectively. As a mother... it pains me to see the cases of malnutrition rising among our children. I feel the urgency—we can’t afford to wait any longer. It seems so important to have a nutritionist present... because I hear from others in neighbouring health centres that they have access to this essential support.” (A 27-year-old mother from Ruhango District with a 9-month-old child and two other children at home).

Mothers advocated for the extension of nutrition initiatives to communities through outreach programs. While some individuals were motivated by incentives, others believed that outreach programs could bridge the gap and engage those who lacked access to these benefits and did not attend the program in their primary health care facility. This viewpoint was summarized by a mother who remarked: “Even though it seems... these programs are in place, they aren’t accessible to everyone. I feel this deeply in my heart. It’s frustrating to know... there are resources and support out there, yet many of us in our community are left out. Sometimes... I think about the mothers who live far away from clinics... or those who can’t easily attend meetings because of their responsibilities at home.” (A 32-year-old mother from Nyabihu District with an 18-month-old child and three other children at home).

Our study indicates that Rwandan mothers recognize the detrimental effects of child undernutrition and value the services provided by health centers and the outreach program, including nutrition education, growth monitoring, and food supplementation. They expressed appreciation for the support offered by CHWs through home visits, which facilitated communication and enhanced their awareness of available services and the importance of child nutrition. However, mothers faced significant challenges in managing multiple appointments for various child health programs while balancing caregiving responsibilities and additional work commitments. Barriers such as long waiting times at health centers and lengthy travel distances affected their ability to access growth monitoring and nutrition services. Although outreach programs delivered by CHWs can help mitigate these barriers, the quality and type of services provided through these programs may not match the level of care delivered by trained health professionals, such as nutritionists, at the facilities.

Our findings indicate that incentives play a significant role in motivating consistent attendance and overcoming barriers to engagement in food-based programs. Participants' perceptions of the FBF program incentives notably influenced their level of engagement, with many expressing a sense of obligation to attend. This may suggest that introducing modest incentives in other components of nutrition services could enhance sustained engagement and improve inclusivity (26). Evidence from various studies indicates that financial or material incentives can effectively encourage individuals to seek care at health centers, where higher-level nutrition interventions are provided. For instance, the implementation of cash transfer programs in Tanzania has demonstrated positive impacts on health-seeking behaviors and service utilization. These programs incentivize families to regularly attend health facilities for care, thereby improving access to vital nutrition services (27). Additionally, another trial in Tanzania demonstrated that such financial incentives significantly enhanced attendance at healthcare services in general, which contributed to better child health outcomes (28). However, it is essential to acknowledge that providing incentives may also pose some disadvantages. The sustainability of these incentives is a critical concern; over-reliance on financial or material rewards could undermine intrinsic motivation and lead to challenges when such incentives are reduced or removed (29). Furthermore, there is a risk of creating inequities if certain groups are unable to access or benefit from incentives, which could hinder overall engagement and program effectiveness (30). Recognizing these potential drawbacks is crucial for developing comprehensive strategies that not only focus on improving health outcomes but also ensure the long-term sustainability of nutrition-focused interventions (31). Evidence from various studies indicates that while incentives can enhance health-seeking behavior, they must be carefully designed to avoid negative consequences (32, 33) .

Participants consistently highlighted the challenge of long waiting times for appointments, which significantly impacted their access to health services and overall engagement in nutrition programs. Prolonged waiting times can lead to decreased patient satisfaction and decreased continuity of care, exacerbating health disparities among vulnerable populations (34). While training and hiring more health workers is an important long-term strategy to address this concern, it is essential to consider immediate solutions that can enhance service delivery in the meantime. CHWs play a vital role in the health care system in Rwanda, serving as trusted facilitators between the community and primary health care services. Expanding nutrition initiatives through targeted outreach efforts can help overcome barriers associated with long waiting times and travel distances to health centers. Research suggests that enhancing the role of CHWs in health service delivery can bridge gaps in care, improve health outcomes, and facilitate access to nutrition programs for underserved populations (35). In addition, the integration of services can simplify the process for families and reduce the time and effort required to attend multiple appointments. A systematic review from Cochrane highlights how integrated service delivery can enhance access and efficiency in child health programs (36). Additionally, UNICEF’s Child Health Days program provides a relevant model for incorporating comprehensive health education and support at the community level, helping families prioritize essential services (37).

Balancing limited resources while caring for multiple children was a significant challenge for mothers, with immediate needs often conflicting with long-term well-being. To alleviate this burden, targeted support programs that address financial challenges faced by families, such as subsidies for healthcare costs or childcare assistance, would most likely be helpful. These initiatives can relieve pressure on mothers, enabling them to prioritize their children's long-term well-being without sacrificing immediate needs (38).

Our results indicated that societal and cultural factors influence mothers' experiences of community and health center visits with many mothers expressing feelings of scrutiny and stigma in seeking nutrition services. Other studies have also found that societal norms influence mothers' ability to prioritize optimal nutrition for their children (39). This highlights the importance of addressing societal factors, particularly the role of community-based education programs in dispelling myths, reducing stigma, and empowering mothers to make informed healthcare decisions (40). The findings also suggest that family dynamics significantly influence mothers’ perceptions of nutrition, as they often encounter conflicting opinions from family members (41). Recognizing this, it is crucial to engage not only mothers but also broader family units in educational initiatives (42). Community-based programs can create an environment that supports mothers’ health-seeking behaviors and strengthens their capacity to advocate for their children's nutritional needs.

Study strengths

Our study included health centers from diverse districts with varying stunting rates, and we interviewed mothers from different backgrounds, including regular attendees, individuals who defaulted, and both FBF and non-FBF beneficiaries. This variation enhances the credibility of our findings and suggests that they may be applicable to other settings in Rwanda. By including information from multiple sources and engaging stakeholders in the process, we believe our findings reflect the current landscape of child nutrition services in Rwanda and that our findings can provide relevant real- world input to address important gaps in service delivery in Rwanda.

Study limitations

Our study had several limitations. It was conducted during the COVID-19 pandemic lockdown, which disrupted service utilization at public primary health facilities. This disruption may have influenced mothers’ perceptions of nutrition services. Additionally, the interview setting at health centers may have affected respondents' willingness to express criticism of the nutrition programs due to concerns about potential negative consequences. However, all participants were informed that the data collected would be kept confidential and would not be used against them, which aimed to encourage honest and open feedback. We also recognize that the interviewer' academic affiliations and perceived societal standing, particularly as an educated man from Kigali, may have influenced how participants viewed him. Mothers might have seen him as a representative of the system, potentially leading to hesitancy or reluctance in sharing honest experiences. To address this concern and mitigate potential bias in participants’ responses, it was essential for the researcher to communicate his own background of being born and raised in a rural village in Rwanda with similar challenges as they might experience. The higher age of the interviewer compared to the participants may have affected openness and honesty due to perceived generational differences. Conversely, a younger researcher may have been perceived as lacking experience or authority, which could have affected the participants’ willingness to share candidly about their challenges and perspectives.

This study indicated that the main challenges mothers face in relation to child nutrition services are the need to balance livelihood activities with multiple health facility appointments, long waiting times and long travel distances. Outreach programs, integration of child health services and efforts to reduce the stigma associated with seeking help for undernutrition may improve participation in the national nutrition program for children.

Contributions

E.R. led the study conceptualization and administration, data curation, formal analysis, data interpretation, and drafting of the original manuscript, as well as responding to reviewers' feedback for the final manuscript.

I.F.S. contributed to data interpretation, restructured the original manuscript, and provided leadership in guiding the incorporation of reviewers' feedback.

J.F.F. was involved in the study conceptualization, data collection, formal analysis, data interpretation, results presentation, and manuscript editing.

D.K.T. contributed to study conceptualization, project administration, stakeholder engagement, and funding acquisition.

K.M. participated in study conceptualization, development of the theoretical framework, and manuscript editing.

M.V. contributed to study conceptualization, development of the theoretical framework, and manuscript editing.

T.U. assisted with data collection and formal analysis.

E.P. contributed to study conceptualization, formal analysis, data interpretation, results presentation, and manuscript editing.

All authors critically reviewed the manuscript and provided final approval for publication.

University of Rwanda

UiB

University of Bergen

CISMAC

Centre for Intervention Science in Maternal and Child Health

CEBE

Rwanda's Regional Center of Excellence in Biomedical Engineering and e-health

RBC

Rwanda Biomedical Center

FBF

Fortified Blended Food

HMIS

Health Management Information System

DHIS2

Digital Health Interventions version two

CRVS

Civil Registration and Vitals Statistics

CHWs

Community health workers

SISCom

Community Health Workers Information System

NNP

National Nutrition Program

HBM

Health Belief Model

NSDS

Nutrition-Sensitive Direct Support

SRP

Stunting Reduction Program

NECDP

Rwanda's National Early Childhood Development Programme

eLMIS

electronic Logistics Management Information System

IMCI

Integrated Management for Child Illnesses

DHIS2

District Health Information System Version Two

SMS

Short Message Service

COREQ

Consolidated Criteria for Reporting Qualitative Research

HISP

Health Information System Program

Contributions

I.F.S. contributed to data interpretation, restructured the original manuscript, and provided leadership in guiding the incorporation of reviewers' feedback.

J.F.F. was involved in the study conceptualization, data collection, formal analysis, data interpretation, results presentation, and manuscript editing.

D.K.T. contributed to study conceptualization, project administration, stakeholder engagement, and funding acquisition.

K.M. participated in study conceptualization, development of the theoretical framework, and manuscript editing.

M.V. contributed to study conceptualization, development of the theoretical framework, and manuscript editing.

T.U. assisted with data collection and formal analysis.

E.P. contributed to study conceptualization, formal analysis, data interpretation, results presentation, and manuscript editing.

All authors critically reviewed the manuscript and provided final approval for publication.

Acknowledgment:

We extend our sincere gratitude to the Rwanda Ministry of Health, Rwanda Biomedical Centre, and HISP Rwanda for their invaluable support in validating the content of this study. We also wish to thank the management of the health centers and all the study participants for their contributions. Special thanks are due to Nancy EIK-NES from the Norwegian University of Science and Technology (NTNU) for her significant assistance in enhancing the language of the initial draft of the manuscript. We are particularly grateful to Elie Nzeyimana Makeba, the CEBE project coordinator, for his support throughout the research project. Lastly, I would like to express my appreciation to Michael Mugisha for his crucial role in introducing us to our initial primary supervisor.

Conflict of interest

None to declare

Ethics approval and consent to participate:

Ethical approval was obtained from the Rwanda National Ethics Committee (REC) (Reference number: 027/RNEC/2021), the Regional Committee for Medical and Health Research Ethics, Norway (Reference number: 267441), and the Rwanda Ministry of Health's National Health Research Committee (NHRC) (REF NHRC/2021/PROT/001). Prior to interviews, participants were briefed about the study's objectives and their right to withdraw. Written consent was obtained from all participants.

Consent for publication:

Not applicable.

Availability of data and materials:
The data generated and analyzed during this study are not publicly available due to privacy concerns but are available upon reasonable request to the corresponding author.

Funding:

This research was supported by the African Development Bank loan to the University of Rwanda's Regional Centre of Excellence in Biomedical Engineering and e-health (CEBE), that financially supported the lead author through a PhD scholarship.

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Supplementary File 6 is not available with this version.

The authors declare no competing interests.

SupplementaryFile1Indepthinterviewsandalistofprobingquestionsdevelopedtoguideinterviewswithcaregiversprimarilymothers.pdf
Supplementary File 1: In-depth interviews and a list of probing questions developed to guide interviews with caregivers, primarily mothers.
SupplementaryFile3ApprovalletterfromtheNationalHealthResearchCommittee.pdf
Supplementary File 3: Approval letter from the National Health Research Committee (NHRC).
SupplementaryFile2EthicsapprovalletterfromtheRwandaNationalEthicsCommittee.pdf
Supplementary File 2: Ethics approval letter from the Rwanda National Ethics Committee (RNEC).
SupplementaryFile4EthicsapprovalletterfromtheRegionalCommitteeforMedicalandHealthResearchEthics.pdf
Supplementary File 4: Ethics approval letter from the Regional Committee for Medical and Health Research Ethics (REK).
SupplementaryFile5RecommendationsforResearchCollaboration.pdf
Supplementary File 5: Consolidated criteria for reporting qualitative research (COREQ) guidelines relevant to the study.

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Mothers' Perceptions of Child Nutrition and Growth Monitoring: Insights and Challenges within Rwanda's National Nutrition Program.

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