QUALITATIVE ANALYSIS OF THE USE OF

NUTRIBUTTER IN PCIS SALTAR PROGRAM

IN NICARAGUA
A CASE STUDY OF DISTRIBUTION THROUGH A MINISTRY
OF HEALTH AND NGO-SUPPORTED PROGRAM

AUTHORS:
ANITA CHARY, MA, MD/PHD CANDIDATE, DEPARTMENT OF ANTHROPOLOGY,
WASHINGTON UNIVERSITY IN ST. LOUIS
GRACIELLA MARSAL, MPH, PRACTICING SOCIOLOGIST, CENTRO DE ESTUDIOS Y
PROMOCION SOCIAL (CEPS)
ALBA ALVARADO, MD, MPH, PRACTICING PEDIATRICIAN, CENTRO DE ESTUDIOS Y
PROMOCION SOCIAL (CEPS)

ACKNOWLEDGEMENTS
PCI and Edesia collaborated to implement this study. Edesia funded the study and PCI undertook the research. Edesia Inc. is a nonprofit
manufacturer and distributor of ready-to-use foods (RUFs) for use in the prevention of child malnutrition. In addition to manufacturing RUFs,
Edesia also partners on research and development to improve RUF distribution systems. PCI is an international development organization,
founded in 1961, that operates in 16 countries to provide integrated and synergistic programming in the areas of: health and nutrition; food
and livelihood security; water and sanitation; humanitarian assistance/disaster risk management; and disease prevention and mitigation.
Independent consultants from the Centro de Estudios y Promocion Social (CEPS) based in Nicaragua, and a researcher from Washington
University in St. Louis were sub-contracted to undertake all data collection and qualitative data analysis. The content of this case study,
authored by Anita Chary, is based on excerpts from the full report Impact of Nutributter on the Feeding and Nutrition of Children Under
Two Years of Age. Jinotega, Nicaragua December 2013 authored by Graciella Marsal and Alba Alvarado which is available upon request.
Nicole Henretty (Edesia) reviewed the case study prior to publication.

Disclaimer:The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International
Development (USAID) or the U.S. government.

INTRODUCTION
Undernutrition affects millions of children in the developing
world. It is caused by many factors, including inadequate
nutrition during pregnancy, low weight at birth, inadequate
care or feeding practices, poor sanitation, poor diets and
nutrient deficiencies, and repeated bouts of illness that
accumulate to affect a childs growth.1 Deprivations that cause
undernutrition in the first two years of life may also reduce a
childs brain development and learning ability, and the effects
may be irreversible.2
The complementary feeding period from the introduction
of solid foods at six months to weaning at approximately
two years brings challenges in adequately meeting nutrient
requirements. Children during this period require nutrient
dense foods that can be difficult for families to provide if they
cannot afford a diverse diet with frequent consumption of
animal-source foods.3,4
One strategy to meet the high nutrient requirements of
certain groups, such as children from six to 24 months, is home
fortification. Home fortification is an approach by which pre-

The first LNS product was developed for a study in Ghana,

in which researchers found that children receiving LNS
experienced improved growth and accelerated motor
development in comparison to children receiving other
supplements.5 Other studies in Malawi among underweight
infants found that supplementation with LNS promoted
sustained growth, reduced the risk of severe stunting, and
improved hemoglobin levels.6,7,8 Currently, there are many
ongoing studies examining the acceptability and effectiveness
of LNS products around the world.9
5 Adu-Afarwuah S, et al., 2007. Randomized comparison of 3 types of
micronutrient supplements for home fortification of complementary foods
in Ghana: effects on growth and motor development. The American journal
of clinical nutrition, 86(2), pp.412-20.
6 Kuusipalo H, et al., 2006. Growth and change in blood haemoglobin
concentration among underweight Malawian infants receiving
fortified spreads for 12 weeks: a preliminary trial. Journal of pediatric
gastroenterology and nutrition, 43(4), pp.525-32.

1 Black RE, et al., 2008. Maternal and child undernutrition: global

and regional exposures and health consequences. The Lancet, Jan
19;371(9608):243-60.
2 Victora CG, et al. 2008. Maternal and child undernutrition: consequences
for adult health and human capital. The Lancet, Jan 26;371(9609):340-57.
3 Vitta B & Dewey KG, 2012. Identifying Micronutrient Gaps in the Diets
of Breastfed 611-month-old infants in Bangladesh, Ethiopia, and Viet Nam
using Linear Programming. Alive & Thrive: Washington, DC.
4 FANTA III Project, 2013. Summary Report: Development of EvidenceBased Dietary Recommendations for Children, Pregnant Women, and
Lactating Women Living in the Western Highlands in Guatemala. FHI360/
FANTA: Washington DC.

dosed, targeted micronutrients are added directly to a childs

food. Currently, there are two main types of home fortificants:
micronutrient powders (MNP) and Lipid-based Nutrient
Supplement (LNS). LNS products are different from MPN as
they provide both micro- and macronutrients. LNS products
are typically sweet, peanut and milk-based spreads packaged
in individual packets. Nutributter is one popular commercial
brand used by international organizations.

7 Phuka JC, et al., 2008. Complementary feeding with fortified spread

and incidence of severe stunting in 6- to 18-month-old rural Malawians.
Archives of pediatrics & adolescent medicine, 162(7), pp.619-26.
8 Manary MJ, et al., 2009. Post-intervention growth of Malawian children
who received 12-mo dietary complementation with a lipid-based nutrient
supplement or maize-soy flour. American Journal of Clinical Nutrition,
pp.382-390.
9 International Lipid-Based Nutrient Supplements (iLiNS) Project: www.
ilins.org

Page 3

Nicaraguas government recently prioritized addressing

malnutrition in several ways. These include establishing
programs to improve economic development and create
jobs for vulnerable families, as well as expanding coverage of
healthcare services through the Ministry of Health (MOH;
Ministerio de Salud).
The latter efforts have specifically focused on monitoring
child growth and development and delivering a complete
vaccination scheme. However, scaling up these efforts has
proved challenging, as evidenced by the persistence of extreme
poverty and high levels of food vulnerabilities in rural areas of
the country.

Governments around the world are looking to focus on

and invest in the prevention of malnutrition, and innovative
strategies are needed. Community-based delivery platforms
represent one promising avenue for scaling up coverage of
nutrition interventions, as they have the potential to reach
poor populations through creating local demand for services
and encouraging household service delivery. Nutrient
supplementation and food fortification can make positive
contributions to community nutrition programs and national
nutrition initiatives when used in combination with activities
that support essential nutrition actions (ENAs), such as
counseling on optimal breastfeeding and other feeding and
care practices. More information is needed on the use of LNS
products in large-scale, government-supported programs.

CASE STUDY: PROJECT CONCERN

INTERNATIONAL (PCI) AND
NICARAGUAN MINISTRY OF
HEALTHS SALTAR PROGRAM
Through the United States Agency for International
Development (USAID) International Relief Partnership (IFRP)
program, more than 16 programs in 11 countries have begun
distributing Nutributter.Through this program, over 65 million
sachets of Nutributter have been used around the world.
One such program is being implemented by Project Concern
International (PCI) in Nicaragua, a country characterized by
widespread poverty and high rates of child malnutrition.10

10 Stunting: 22%; UNICEF, 2008-2012. Severe Acute Malnutrition: 2.1%,

Moderate Acute Malnutrition: 4.9%; Encuesta Nicaragense de Demografa
y Salud, 2011-12.

In this context, PCI implemented the SALTAR program

(Seguridad ALimentaria: Tecnicas y Apoyo para Resultados / Food
Security: Skills and Support for Results) in collaboration with
the Nicaraguan MOH to offer LNS distribution as part of
established MOH nutrition programming aiming to improve
the health and nutrition status of children six to 23 months
of age. LNS distribution took place as part of this program in
the department of Jinotega, one of the poorest departments
with the highest rates of malnutrition in the country,11 as
well as in the department of Managua. SALTAR programming
included providing technical assistance and training to 550
health personnelspecifically, 50 MOH personnel and
500 community health volunteersas well as providing
nutrition and health counselling and a supply of Nutributter
to caregivers of 7,000 infants aged six to 23 months in
impoverished rural communities. Technical assistance included
training on essential nutrition actions (ENA), hygiene and
sanitation, health, the use and management of Nutributter, and
how to grow micronutrient-rich foods in home gardens. An
additional 18,000 family members indirectly benefited from
the program through increased health and nutrition education
of caretakers. PCI coordinated the SALTAR programs with
28 MOH health facilities (Centers and Posts12), one hospital,
and community programs in the departments of Jinotega and
Managua.
In each municipality, SALTAR programs were integrated into
MOH nutrition program services of Growth Monitoring
& Promotion (GMP), part of the Surveillance, Promotion,
Growth and Development Program (Vigilancia, Promocin,
Crecimiento y Desarrollo,VPCD), as well as an MOH-sponsored
Expanded Immunization Program (Programa Ampliado de
Inmunizaciones, PAI) at the health units. SALTAR program
11 Severe Acute Malnutrition: 1.3%, Moderate Acute Malnutrition: 11.4%;
Encuesta Nicaragense de Demografa y Salud, 2011-12. INIDE (Instituto
Nacional de Informacin de Desarrollo), 2005.
12 Collectively referred to as health units in this report.

Page 4

activities also occurred through community-based MOH

GMP services that are provided through a Community Health
and Nutrition Program (Programa Comunitario de Salud y
Nutricin, PROCOSAN) using volunteer community health
brigades. Through PROCOSAN, communities identify and
mobilize Community Health Volunteers (CHV, brigadistas)
to receive training from and work with MOH personnel. In
addition to fulfilling basic primary care and health training and
referral functions, CHVs conduct monthly GMP sessions and
provide health counseling and educational talks to community
members and infant caregivers. For SALTAR programs, both
health facility personnel and community health volunteers
were responsible for registering child growth on the childrens
health cards and following up with those who demonstrated
unsatisfactory growth. CHVs also collaborated with MOH
staff to conduct health fairs.
Through SALTAR, Nutributter supplements were distributed
monthly to caretakers for beneficiary children during
attendance at: 1) MOH health units for GMP or health visits; or
2) community health and GMP programs led by CHVs. A takehome Nutributter ration of thirty 20g sachets (i.e. one 20g
sachet per day) was also distributed to each beneficiarys child
(6-23 months of age) and their caregivers who participated in
GMP sessions.
Because PCIs SALTAR program relies heavily on coordination
with the Nicaraguan Government, the MOH-supported
health facilities, and community health personnel, it was ideally
suited to study the effect that Nutributter distribution has on
existing health systems. The research highlights SALTAR as a
case study that provides insights into operational questions
related to distribution channels. Furthermore, SALTAR
serves as an example of how nutrition supplementation can
be incorporated into current NGO and MOH nutrition and
health programs.

In addition, data about current feeding and care behaviors

of young children, perceptions of malnutrition and illness,
and food security were also collected to establish the local
context of the SALTAR intervention.
The study design is rooted in formative research methods
focusing on process rather than on quantitative results.All data
collection and analysis was done by independent researchers
hired as consultants.
GEOGRAPHICAL AREA OF STUDY
PCI implemented SALTAR in five municipalities located in
the Department of Jinotega including: Jinotega; Santa Mara
de Pantasma; El Cua; Wiwil, and San Jos de Bocay. Each
municipality has approximately 100 communities served by
the project.
DATA COLLECTION METHODS
Key Informant Interviews
Study researchers conducted thirty-five semi-structured
interviews with key personnel participating in all levels of the
SALTAR program: Ministry of Health staff in hospitals, health
centers, and health posts; community health brigade volunteers
and other community leaders; and PCI staff. Interview topics
included perceptions of: how cultural beliefs, perceptions,

STUDY DESIGN
A qualitative study was undertaken to examine stakeholder
experiences of LNS distribution through the PCI-MOH
partnership in the department of Jinotega, Nicaragua, one
of the first large-scale LNS distributions through MOHsupported nutrition activities in Latin America. This research
sought to assess:
(1) the impact of adding a LNS supplement to existing
health care structures.
(2) the feasibility of using LNS supplementation as a tool
for promoting attendance to MOH health and nutrition
programs.
Page 5

supplements in the municipalities of Pantasma, El Ca, and

San Jos de Bocay. Caregivers included 31 mothers and one
grandmother whose ages ranged from 15 to 49. Researchers
used a structured guide to generate discussion about local
perceptions of malnutrition and food security; childcare beliefs
and practices; acceptability, use of Nutributter; and perceptions
of the SALTAR program. Focus group discussions lasted
approximately 60-70 minutes and were digitally recorded,
with participant permission. Recordings were transcribed
verbatim by native Spanish-speakers.
Type of
Participants

Selection
Criteria

Community Health
Volunteers (CHV)

and economics influence and affect feeding practices of

young children (e.g. malnutrition, food insecurity, childcare
beliefs and practices); how Nutributter programming fits into
existing community programs; successes and challenges of
SALTAR program design and implementation; impact of LNS
on health services and healthcare staff; and acceptability and
use of the Nutributter supplement. Interviews ranged from
20-40 minutes and were digitally recorded, with interviewee
permission, and transcribed verbatim by native Spanishspeakers.
Type of
Selection
Participants
Criteria
Mothers/Caretakers Caretakers whose children
of children 6-23
are targeted by the SALTAR
months of age
program and received
Nutributter

Number of
Participants
32 total
participants
in three
separate
focus group
discussions

Recognized as health
volunteers in the
community and certified
by the MOH
MOH Health
Employees of the MOH
Facility Staff
involved in the technical
aspects of service delivery
for SALTAR
Community Leaders Recognized as leaders
by the communities and
corresponding health
facilities (3 men, 8
women)
PCI Program Staff
Director and technical
level staff of PCI
responsable for SALTAR
implementation
TOTAL

Number of
Participants
10

11

11

35

DATA ANALYSIS
Researchers generated a codebook based on topics of interview
and focus group schedules as well as preliminary review of
verbatim transcripts. Transcripts were coded for dominant
themes, which were then categorized based on similarities
in experiences and viewpoints. Codes and categories were
organized by informant type (e.g. health personnel, community
leader, PCI staff, caregiver, etc.) in matrices, which facilitated
comparison of themes based on stakeholder position and
participation within the SALTAR program.

RESULTS AND DISCUSSION

Focus groups

CONTEXT: POVERTY, FOOD INSECURITY, AND

CARE PRACTICES

Three focus group discussions were conducted with a total

of 32 primary female caregivers of children six to 23 months
participating in the SALTAR program and receiving Nutributter

To understand the context of the SALTAR program,

researchers elicited study participants perceptions about
common determinants of young child health and nutrition.

Page 6

Frequently mentioned topics included poverty, food insecurity, nutrient consumption. During focus groups, mothers often
family characteristics, as well as local health beliefs, culture, reported feeding children what is readily available depending on
the season or month, whether due to agricultural production
and dietary practices.
or the familys financial situation at the moment.
Jinotega and many of its municipalities are characterized as
In remote communities, such as Ayapal, children are fed
highly vulnerable in terms of poverty, unemployment, and low
only beans, tortillas, and curdled milk (cheese). Children
income.The majority of those interviewed reported that large
are suffering from considerable growth and development
family size (numerous children), cramped living conditions,
deficiencies, and are malnourished. (Health Post).
limited basic services and infrastructure, and cultural beliefs
and practices negatively impact families abilities to acquire or
I am going to tell it to you straight. Sometimes we only
utilize nutritious food. These factors were perceived as largely
have beans, at times we have no rice or sugar. There are
related to precarious household financial situations in the
months like June and July when there is little work. Only the
region: in rural municipalities of Jinotega, generally only one
men work, and there is very little money.(Caregiver).
household member is employed on a temporary or seasonal
basis in a low paying job.
Many families have a small plot of land for agricultural use.
Health care personnel reported that food insecurity in
Jinotega impacts family dynamics and food distribution.
Men preferentially receive nutrient-rich foods due to their
roles as breadwinners who perform strenuous labor. Such
distribution can detrimentally impact the youngest children
in a household, especially as they start to transition from
exclusive breastfeeding to the consumption of foods eaten by
the rest of the family.

However, health care personnel reported that due to

economic necessity or lack of awareness of the nutritional
value of foods, families sell these products and feed their
children foods of low nutritional value.
We have foods that people here do not eat, but instead
sell in exchange for foods that are bad for their childrens
health. (Health Center).
One example would be [for a mother] to give eggs to
her children instead of selling the eggs, because eggs have
protein. Use things in the communty to feed the family.
Here there are a lot of oranges--which are high in vitamin
Cbut people sell them as part of their businesses.
(Health Center).

Often people in rural areas give priority to the husband,

as he is part of the labor force, and so the best must be
for him. Because of this, children are denied the nutrients
contained in eggs and chicken. (Health Center).

Health care providers reported that economic limitations and

geographical remoteness also influence norms of inadequate,
routine, and monotonous food preparation, which constrains PERCEPTIONS OF MALNUTRITION IN THE
COMMUNITIES

Community health volunteers, community leaders, PCI staff,

and MOH personnel in health units were asked about signs
and causes of malnutrition, as well as their opinions about the
severity of malnutrition in the region. According to a number
of MOH and PCI personnel, chronic malnutrition13 is the most
persistent type of malnutrition, but acute malnutrition is more
easily diagnosed.While the majority of community interviewees
spoke in a general way about the signs of malnutrition, it was
worth noting how they identified the effects of malnutrition
on childrens lives.
Not only are these children haggard, thin, with their
ribs showing. They come to you showing signs of
apathy or are badly behaved (if they are older). Their
13 It should be noted that most growth monitoring during GMP sessions
consisted of measuring weight, and not height. Therefore, CHVs references
to malnutrition throughout this text tend to signify a child being
underweight (low weight-for-age).

Page 7

have difficulty monitoring and influencing what goes on.

(Health Post).

hair changes, becomes thinner and paler in color. Their

skin gets drierwell, there are lots of different signs.
(Pediatric Department, Hospital).

In our community the health brigades (community health

volunteers) are very active; they weigh the children, we
mothers find out if our childrens weight has gone up or
down, and why it has gone down. Then we get worried,
and we feed our children more, and bring them to the
health center to see what the problem is. (Community
leader).

I think malnutrition means the loss of agility in children.

Their brains cannot develop fully nor can their physical
growth.Their development and abilities are not normal.
(Community leader).
Hospital personnel and PCI staff regarded malnutrition as
a major health problem in terms of severity and social and
economic importance. They found it to be a general problem
throughout the entire department of Jinotega, though in
varying degrees of severity, depending on the town and
community.They also noted the vicious cycle created between
common illnesses and malnutrition.
It is a problem. Almost all the children that come to us
with diarrhea or pneumonia are underweight and need
to be hospitalizedoften for a long time. (Nutrition
Department, Hospital).A child that gets sick a lot become
malnourished and a malnourished child get sick a lot. The
problems are married to one another. (PCI staff).

In addition to poverty and food insecurity, many interviewees

felt that local feeding and care practices might contribute to
malnutrition. According to health personnel, during the childs
first six months of life, exclusive breastfeeding is generally not
practiced for more than four months, mothers typically do
not breastfeed children for the recommended frequency or
duration, and caregivers often give their babies other liquids
(water, honey, tea, and coffee). Health staff reported that when
weaning their babies, mothers frequently use foods of little or
no nutritive value including junk food. Health volunteers also
felt that proper sanitation, hygiene, and food safety were not
practiced in many of the communities.

Some health personnel considered malnutrition a problem

that can be controlled through adequate nutrition and health
programming. However, they expressed that the ability to
control malnutrition seems to vary according to the distance
of communities from larger towns.

Children are fed bread and coffee. Such are the customs
and culture here the same food goes to everyone, and
[they] do not differentiate between feeding a growing child,
and feeding an adult. Everyone eats the same. (Nutrition
Department, Hospital).

We identify malnourished children early on, before

their condition becomes very serious. (Health Center).
In Ayapal it isnt such a problem, but in more distant
communities, where access to resources is limited, we

Malnutrition can be prevented by teaching the child to

wash his or her hands. Many infections are spread because
our children do not wash their hands before eating, or
Page 8

follow up on their work in local communities, they feel

very empowered and supported... I consider the volunteer
network to be one of the pillars of the Ministry of Health.
Without them we wouldnt be able to do our work or
have the same impact. (Health Center).

the dish we serve the food to them in isnt clean. Food

needs to be properly prepared so that children do not get
sick. I think malnutrition is at times something we cause
ourselves, and that the family can prevent it. (CHV).
SALTAR PROGRAM
MOH personnel, PCI staff, and CHVs were all asked to
describe their roles within the SALTAR programming.
Discussions centered on their interactions with other SALTAR
collaborators and community members; their experiences
of distributing Nutributter; their perceptions of community
members acceptance of Nutributter; and programmatic
challenges. Interviewees were also questioned about their
opinion on the roles that other institutions should play in
addressing child malnutrition in Nicaragua. Additionally, during
focus groups, caregivers of beneficiary children were asked
about SALTAR and their perceptions of Nutributter.
Program coordination
As previously described, caretakers and their children
participate in the SALTAR program through visiting MOH
Health Centers, Health Posts, or community programs that
are organized by community health workers. The SALTAR
program closely integrates into many MOH-supported
programs at the health units, especially programs that have a
strong child health and nutrition component.

Our role as health volunteers consists of helping keep

our community free from maternal and child deaths,
helping it become a healthy community. Thats what we
strive for. Thats why we volunteer our time day and night,
winter or summer. (CHV).
When asked about the role of NGOs in child health and
nutrition, MOH staff reported that the work of NGOs
should be aimed at strengthening existing efforts, and that
all organizations present in the territory should complement
each others abilities and experiences to avoid repetitive or
overlapping activities. Underscoring this point, some health
staff claimed that while malnutrition is still a problem, the
situation has improved in recent years, thanks to the efforts of
the community and the support received from organizations
such as PCI.

As the Ministry of Health, the [growth] monitoring and

promotion that we conduct is aimed mainly at sensitizing
mothers about what to do and when to do it, in order
to prevent child malnutrition. We want to teach mothers
how to take care of their children before they develop a
chronic problem. (Health Post).
Volunteer networks operate in coordination with both the
MOH and NGOs working in their communities. Community
health volunteers receive training by MOH and NGO staff
in order to improve their knowledge and skills, as well as
their capacities to transfer the knowledge acquired to the
overall communities. All MOH respondents recognized the
work conducted by volunteers, as well as the enthusiasm and
dedication with which they perform it.
We build a chain: we train volunteers and they in turn
pass down this information to the communities. Health
volunteers are both receivers and transmitters of the
information at the same time. (Health Center).
The community health network is composed of
volunteers who are always eager and enthusiastic to
participate in trainings. Whenever we conduct visits to
Page 9

PCI and based on the request of health directors at the

municipal level. This system ensures full coverage in such a
way to avoid any possible shortages. PCI warehouses the full
year supply of Nutributter and dispatches it each month to
each distribution site.
Health units store the Nutributter in their pharmacies, with
great care placed on product conservation by controlling
climatic and rodent factors. MOH personnel interviewed also
added that there are administrative controls in place (stock
inventories) to ensure the proper delivery to other health
units and community health workers.
From the Health Centers/Posts, community health workers
pick up product for their community-based GMP activities that
are taking place in more remote locations. MOH staff reported
the importance of coordinating Nutributter distribution with
community health volunteers. In very remote communities,
CHVs play an indispensable role by traveling to the health unit
every month to receive the Nutributter supplements to take
to the communities.
They [NGOs] have a lot to contribute, but need to
coordinate under the guidance of the Ministry of Health.
All NGOs should be allowed to work here, because they
address so many topics: children, pregnant women or
women using family planning (Pediatrics Department;
Hospital).
If you compare the situation with past years, things have
improved and PCI has played a fundamental role in that:
food for work; feeding pregnant women and children.
And not only that, the best part is that this help has
been accompanied by education and awareness-raising.
(Health Center).
Nutributter distribution component

In the community, distribution is conducted by health

volunteers. They have their weight scale [and] their
notebook, which are kept in the clinic or health post.
They do the work and come back with the information.
(Health Center).
MOH staff maintained documentation on the amount of
Nutributter distributed by each health unit and CHV. Once
a month, the health unit director reviews these records,
then consolidates them and submits them to the MOH
Comprehensive Childhood, Maternal, and Adolescent Health
Care Program (Atencon Integral a la Niez, Mujer, y Adolescencia,
AINMA). In turn, the person in charge of the AINMA program
consolidates the information for the municipality and writes a
report which is then submitted to the PCI.

The SALTAR program offered Nutributter supplements for

more than two years with the goal of enhancing program
effectiveness in reaching more children while improving their
nutrition. We considered it important to explore the level of
involvement of MOH staff in the SALTAR program and their
opinion on how supplement distribution is conducted.

We have a census of all children six to 24 months of

age in each community; the health volunteer brings this
census to the health post and we do the release. We
attend the weighing sessions that they conduct and at that
moment we do the VPCD control, in order to verify if
the Nutributter is really helping achieve our goal or not.
(Health Center).

MOH staff interviewed reported that the SALTAR program

began in 2012, after the end of a World Food Programme
initiative, which had been providing other commodities. 14
Regarding the operation of the program and its components,
the MOH staff noted that the Nutributter supplements are
distributed to the municipalities in prior coordination with

Community health volunteers expressed that growth

monitoring and integrated child health care sessions are good
platforms to deliver the Nutributter supplements to the
target population.

14 This project gave families, oil, cereal, and sugar, among other foods.

We take advantage of two key moments to say a few

words [to mothers]: first during the weighing session,

Page 10

when we deliver the food, and right at that moment we

coordinate with the MOH to plan the integrated health
visit, which is conducted every two months. (CHV)
Perceptions and acceptance of Nutributter
MOH personnel showed great enthusiasm for Nutributter,
characterizing it as a promising nutritional supplement for
improving child growth and development. All interviewees
expressed that Nutributter is accepted by parents and children
alike. Initially, some mothers felt somewhat apprehensive
towards the supplement given the fact that it was a new
and unknown product. However, after seeing the benefits
of Nutributter, they expressed overwhelming acceptance.
Children like the product, which is evidenced by the fact they
eat it straight out of the packet without the need to mix it
with other foods. Some children want to eat more than one
portion a day.
It helps substitute what is missing in childrens diets; it
has a number of components such as zinc, iron, Vitamin
A, Vitamin B12, protein, potassium, and calcium. It is
composed of lipids. In human physiology, lipids help [a
child] gain weight and provide energy reserve to correct
problems. (Health Post).

MOH personnel,mothers,and community leaders reported

the addition of Nutributter to the program as beneficial,
since they have seen how children are gaining weight,
and are showing satisfactory growth and development,
with positive changes in their behavior. Moreover, health
staff stated that Nutributter has also had an impact on
preventing illnesses related to malnutrition and reducing
treatment and hospitalization. A mother told me: Ive
noticed that my child has grown a huge appetite! He
seemed weak before, wouldnt play or laugh. (Pediatrics
Department; Hospital).
We are helping children prevent a number of illnesses
because if their nutritional status is good then we are
reducing the possibilities of them being hospitalized for
a long period of time. (Pediatrics Department; Hospital).
Children appear to have more color. They grow faster
and some who had not started to walk are already walking.
Its just beautiful. Other products have been distributed in
the past, but this one is really effective. It is an effective
vitamin and it shows in kids faces. (CHV).
Counseling component
During each visit, children are weighed and MOH healthcare
workers and/or health volunteers use graphs to measure
trends in weight gain or loss. Health staff use this information
to counsel caretakers who have children who are underweight.
This counseling was found to play an important role in teaching
mothers and families about the effect of diet and hygiene on
their childrens health and growth. Above all else, healthcare
personnel are taught to promote exclusive breastfeeding
during the first six months of life and the importance of a
balanced and varied diet, with introduction of food starting at
six months of age. Counseling is also used to help caretakers
know how to correctly use Nutributter.
When we do a VPCD check up on a child, and he falls
below normal limits, program guidelines tell us we must
provide counseling to the mother, and take actions to
correct the situation. Even when a child is within normal
limits, we encourage the mother to continue the care she
is providing. (Health Post).
We teach them how to prepare it [Nutributter], so that
their children accept it better. We also teach them how to
give it to their children. We tell them to give their children
only one packet a day.The changes that can occur in children
[in their feces], the reactions their children can present if
they eat more than one packet a day [nausea, vomiting]. All
of these things we explain to mothers. (Health Center).

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up to follow up on any other pathologies the child may

have and prevent any complication or error related to the
treatment prescribed. (Health Center).
When mothers attend the health units for Nutributter
distribution, they also take advantage of the opportunity to seek
health care services for all of their children and for themselves.
MOH staff reported that mothers of beneficiary children are
utilizing more services such as family planning, prenatal checkups, and chronic illness care. This has led to an improvement
in coverage and service utilization of MOH programs in the
overall population, particularly pregnant women and children,
and has also translated into an improvement in nutritional
indicators. This increase in coverage also extends to activities
conducted by health staff in local communities, such as health
education for families, the integrated community health visits,
and health fairs.
Nutributter is our ally, in that it allows us to reach our
coverage [goals]. All the health personnel believe this
to be an excellent opportunity to improve and develop
preventive health work, in order to attract a greater
number children, parents and families and impact their
education and knowledge. (Health Post).
It has helped us reduce the number of malnourished
children, and increase coverage, because by distributing
this small packet more mothers are now attending the
VPCD with their children, which is helping us attract new
children who we were previously not able to follow up on
for 3-5 months. (Health Post).

Programs effect on the health sector

In order to assess perceived effects of the SALTAR program,
including Nutributter distribution, on the health sector and
particularly on health services, we explored the following
themes: change in demand for services; change in number of
services provided; and change in frequency of attendance to
health services.
Healthcare staff were asked about the frequency of visits
through SALTAR (once per month) compared to the MOH
GMP program previously (every two months). Staff felt
monthly visits facilitated the provision of services to both
the child and the mother, thus providing the MOH with a
double opportunity. In this regard, MOH staff stated that it
is preferable that the Nutributter distribution be conducted
monthly, even if it presents more work for both the health
staff and community volunteers.
Its better for us if the child is brought here every month,
because that way can identify any acute health issue. We
also take the opportunity to provide a medical check-

I think Nutributter is contributing to this high turnout,

and our staff is taking advantage of this opportunity:
theyre doing more prevention, more care, more training
and counseling. Especially, they are doing more integrated
maternal and child care. We are making the most of this
opportunity and thats our goal here in our municipality,
particularly in the health post. (Health Post).
Health staff also stated they have observed changes in the
reasons given by beneficiary families for seeking care at the
health units, suggesting an increased interest in prevention.
This has been a result of both the Nutritubtter distribution
and the counseling mothers receive.
I believe it has changed, because mothers would actually
only bring their children whenever they were sick. If the
child had pneumonia, only then would the mother take him
to the health center. But after the nutritional supplement
began to be distributed, they no longer do that. They now
take their children to the health center for vaccination
and weighing. (Health Center).

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because you have to ask yourself: who are the children

Additional impacts of the project that were noted from this
with lower weight? Children under five. (Health Center).
research included a strengthening of community organization,
improved linkages between the community and health units,
and promotion of health volunteers leadership within their MOH staff expressed worry that too much focus could be
placed on Nutributter distribution during GMP and other
communities.
sessions. From an institutional perspective, the MOH staff
revealed that it could be easy to lose sight of the goal and
When the community health workers take part in
focus strictly on distribution, instead of the nutritional
Nutributter distribution they feel they are conducting a
status of beneficiary children. A similar concern was raised
very important work for their communities, and they work
by community leaders who felt that while caretakers value
harder to provide counseling and training to caregivers
receiving Nutributter, they may not have the same value for
regarding the nutritional supplements people also feel
other community health or nutrition services. Interviewees
very satisfied with their work. (Health Center).
felt the situation would become more worrisome after the
Nutributter allows me to achieve my goals as a health
program ended.
post director. (Health Post).
What happens when projects leave? Moms stop attending.
Its happened several times over: with the WFP [program]
Program challenges
there were huge lines of people wanting to weigh and
Informants were asked about to report about challenges
vaccinate their children; they knew that if they were up to
experienced as part of the SALTAR program. Discussion
date with the health programs they would receive their
centered on product transportation and distribution; program
food. (Health Center).
sustainability; the focus of the program; and difficulties related
They come to vaccinate their children because they
to behavior change counseling.
know they will receive the supplement, not because of any
As noted previously, at the beginning of the SALTAR program,
awareness about how the vaccine is good for them. They
Nutributter acceptance was not universal; many families
are getting the idea that they have to attend the weighing
compared Nutributter and other rations they had received
session because they will receive the supplements. They
under a previous project. MOH personnel reported addressing
are doing it for the sake of receiving the supplement and
this challenge by coordinating with PCI to implement a
not for the sake of getting their children vaccinated and
community information and education process with support
weighed. (CHV).
from the CHV network.As a result, implementation and product
The effectiveness of counseling on feeding and care behaviors
distribution was then able to advance more expeditiously.
was also mentioned. Though healthcare staff provided
At first, mothers were not accepting it because it was a
small packet; they were used to receiving rice and beans.
(Health Post).
It [acceptance] has increased, because mothers have seen
how their neighbors child has grown bigger and healthier,
with a better physical condition, than their own child. So,
mothers say to themselves, Well, it looks like its working.
And so they turn to the Nutributter. (Health Post).
A second challenge was on the Nutributter distribution
guidelines. Some caregivers demonstrated discomfort because
they wanted their other children (older than 24 months)
to also have access to the food supplement. This was also a
concern expressed by some health center/post staff as they
felt children between two and four years of age who also show
nutritional deficit could benefit from inclusion in the program.
For me, the most important thing is that the supplement
should be given to all children up to five years of age,
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We have problems in distributing the food from the

health post to the communities. Some health volunteers
have had to hire trucks with their own money in order to
transport the boxes. Sometimes there are up to 15 boxes
and volunteers have to pay the fare. (Health Post).

CONCLUSIONS

information and advice to the population using their services,

they have concerns about how to make health education more
effective at changing mothers and other caregivers behavior
and feeding practices with their children. Participating family
members were usually women, and most often the mother.
Because of this, some interviewees felt that the education and
counseling must also take place within the family itself, so that
all members become key players in nutritional decision-making.
They expressed that it is not only a question of empowering
a childs mother as the primary female caregiver, but also of
building alliances with other household members who can
help her.
What we need is to be able to change peoples attitude.
How can we do that? We provide them counseling, but
our counseling is not getting through enough to bring
about changes in these women. (Health Center).
The man makes the decisions about what needs to be
done, though other adults in the home also have influence-particularly the mother-in-law or the grandmother, as
they have knowledge accumulated from the past that they
are passing on to the new mother. It is theyand not
the motherthat are making the decisions in the home.
(Health Center).
Lastly, one of the most significant challenges reported regarding
the supply process was the transporting of the products from
PCIs warehouse to the target municipalities. Health Post staff
and CHVs located in the more remote and rural communities
reported having to sometimes contribute their own money
for transportation.This becomes problematic as CHVs receive
no monetary compensation for their work and live under the
same conditions of poverty as many of the rest of community
members.

Within the context of widespread poverty and high levels of

childhood stunting in the department of Jinotega, Nicaragua,
this qualitative study examined stakeholders experiences of
the SALTAR program. As SALTAR is carried out in partnership
between PCI, MOH facilities, and local communities, this
research sought to explore: (1) the impact of linking a LNS
supplement with an existent health care system; and (2) the
feasibility of using LNS supplementation as a tool for promoting
attendance to health and nutrition programs.
LNS distribution through SALTAR was found to be feasible
for several reasons. First, caregivers felt Nutributter was a
beneficial product that improved child growth and achievement
of milestones and decreased the frequency of common child
illnesses. Beneficiary children also had a high acceptance of the
product and consumption rates were reportedly high. Second,
local actors, including MOH personnel, community leaders, and
community health volunteers, had sufficient technical capacity
and skills to coordinate the delivery of Nutributter and
disseminate related health information to intended beneficiaries.
Third, systematic communication and coordination between
PCI staff, MOH personnel, and community health volunteers
allowed for adequate stocking, warehousing, distribution, and
inventorying of Nutributter. Fourth, MOH health personnel
saw Nutributter as complementary to the focus on child
health and nutrition within MOH programs and accepted the
addition of the supplement to their usual programming.
Interview data show that the collaborative model of
programming described herein has several major effects on
health systems organization. First, Nutributter distribution
strengthened community health organization by promoting
opportunities for increased visibility of community leaders and
community health volunteers in beneficiary communities at
the local level and MOH health units at the government level.
Second, Nutributter distribution improved linkages between
MOH personnel and community health volunteers, which
led to better coverage of services for remote communities.
Interactions between community health volunteers and MOH
personnel increased as the former coordinated LNS delivery
with and reported growth surveillance data to the latter.Third,
Nutributter distribution helped increase user demand and
access to other MOH-delivered health services for women and

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children through increased exposure of caregivers to MOH

health units. Additionally, positive perceptions of Nutributter
among caregivers appear to translate into increased willingness
to access health units, both for treatment seeking during acute
illnesses, as well as preventive care such as vaccinations and
prenatal care. Although increased use of health units created
additional work for MOH personnel, several expressed that
it represented an opportunity that allowed them to work
towards achieving goals in nutritional and other health
programming. Increased use of health units also facilitated
feelings of productivity, enthusiasm, and motivation for work
among MOH personnel and CHVs.

MOHs can provide coordinated oversight, sites for

distribution, organization, coupling to health services, and
health records keeping; community health volunteers can
work as liaisons between health units and communities.

Programs with a robust system of community health

volunteers, health workers, or health promoters, may be
needed to increase coverage and reach of programming,
especially in locations with rural remote populations or
inadequate transportation. Adequate training and support
is necessary.

GMP and LNS distribution once per month seemed

adequate for both healthcare personnel and caregivers.
However, this may need to be coordinated with MOH
visits and activities differently in other programs and
settings.

The research also highlighted several challenges in the

SALTAR project. First, SALTAR relies on a large network
of uncompensated community health volunteers who must
sometimes use their own money to visit MOH facilities in
order to interact with health care providers and coordinate
Nutributter delivery. Second, community health volunteers do
not receive remuneration for the community-level services
of growth surveillance, health counseling, and the Nutributter
distribution that they provide. Although this system appears
to be working well in Nicaragua, this may pose a challenge in
contexts without a history of community health volunteering.
Third, community and MOH personnel discussed frustrations
about their inabilities to change attitudes and practices among
caregivers related to child feeding and care and the value of
preventative health services. Lastly, community leaders and
health care workers alike expressed fears about Nutributter
program sustainability and perceived that the benefits of
improved child health and increased user demand for MOH
health services would cease once the SALTAR program ended.
Many hoped that Nutributter would continue to be made
available to project beneficiaries free of charge, as local families
were not perceived to have the ability to afford Nutributter.

IMPLICATIONS AND
RECOMMENDATIONS
A number of important lessons learned during the
implementation of the SALTAR program and from the
findings of this research. These findings are useful to take into
consideration when designing future programs that involve
the distribution of Nutributter through similar programs in
Nicaragua, as well as some insight to other settings.

When considering LNS distribution, successful

collaboration between NGOs, the MOH, and the
community is possible. Each sector contributes a different
skill to program management. NGOs can provide
coordinated oversight and logistical/technical assistance;
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STUDY LIMITATIONS AND FUTURE

STUDY
This study had several weaknesses. The first weakness is that
the study has low external validity. The detailed information
garnered about the SALTAR program in Jinotega, Nicaragua
may not be generalizable to other areas of Nicaragua or
elsewhere.Additionally, data were was collected approximately
18 months into SALTAR program implementation, and it is
possible that data collected after the cessation of SALTAR
programming may have yielded different insights and results.
A second weakness is the lack of quantitative data on
indicators such as child growth and utilization of health
services. While interviewees between the various informant
types corroborated much of the information presented in this
report, quantitative data would have provided another level of
insight into the scope of stated improvements. Future research
could focus on gathering quantitative data to compare with
the qualitative information obtained on childrens nutritional
status and health service provision, demand, and coverage.

FINANCIAL DISCLOSURES AND

CONFLICT OF INTEREST STATEMENT

Addition of LNS to MOH child nutrition programs may

encourage use of MOH services. Healthcare personnel
may see an increase in overall workload. However, this
increase in demand and use of services, in addition to the
extra workload of managing and distributing LNS, should
be considered when developing programming. Creating an
understanding of the importance of preventative health
services and appropriate child care practices should be
prioritized. Nutributter distribution can help to initiate
interest in beneficiaries; however, pre-planning efforts are
needed to ensure sustainability of the program.

A more comprehensive behavior-change strategy should

be developed that identifies determinants of behaviors and
targeting those who have the power to influence change.
Programming should engage with families (especially with
fathers and grandmothers) during counseling sessions as
well.

Provision of in-kind foods and/or supplements can

provide a fiscal challenge and lead to poor sustainability
of programming. Additional programming options, such as
choosing a food or supplement that is already available
on the market (or building a market for LNS or other
products), or recovering some of the commodity cost
through beneficiary contribution should be evaluated.

The study was funded in part by Edesia and PCI. Consultants

from CEPS were employed by PCI. Travel expenses for the
researcher from Washington University in St. Louis were in
part funded by Edesia.

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