Beginning in 2010, the Ministry of Health and Population in Nepal, in collaboration with UNICEF, piloted an integrated IYCF/MNP program designed to provide all children 6–23 months of age with 60 sachets of MNP every 6 months (total of 180 sachets for each child entering the program at 6 months of age). The MNP were locally branded as Baal Vita. Two pilot districts were selected from each of the three ecozones: plains (Rupandehi and Parsa), hill (Makwanpur and Palpa) and mountain (Gorkha and Rasuwa). In Nepal, 83% of the population lives in rural areas¹⁰ and different MNP delivery models were piloted in rural and urban areas of each district. The program had a staggered start across districts and in rural vs. urban areas of each district. The program included identical behaviour change intervention strategies in all districts/models and were distributed through mass communication (radio advertisements, billboards, stickers on female community health volunteer homes), written materials (distribution of brochures and reminder cards) and MNP/IYCF counselling (delivered through monthly mothers group meetings with community volunteers, routine personal encounters with community volunteers, and/or through local health facility staff). Additional details about the pilot program and monitoring surveys are published elsewhere.^11,12

A cross-sectional household survey was conducted by an external survey organization in several locations during the pilot for program monitoring of this public health intervention. These surveys were representative of all children 6–23 months and were conducted within three months of each other in 2011. Due to the staggered roll out of the program in each district and in rural vs. urban settings, the surveys reflected different time points in two different program settings: 3 months after program implementation in rural and urban areas of Rupandehi and Parsa (plains districts) to assess a newly started program and 15 months after implementation in rural areas only of Makwanpur and Palpa (hill districts) to assess a longer standing program. There were no surveys in the pilot districts located in the mountain ecozone, or in urban areas of Makwanpur and Palpa districts. Using population proportion to size sampling, 30 clusters from each rural district and 30 clusters from urban municipalities across Rupandehi and Parsa were selected (representative of rural areas of each district and representative of urban areas across Rupandehi and Parsa). Within each cluster, a household census was conducted to identify all eligible children; 12 children 6 to 23 months from each cluster were then randomly selected for a household interview for a sample size of 360 participants per survey. Interviews were conducted with mothers of selected children about program exposure and MNP and IYCF knowledge, experiences, and practices, including MNP intake. There was no replacement for refusals or if there were less than 12 eligible children in a cluster.

Due to the potential benefits of MNP program intervention for older children and lack of baseline information about acceptability for purchasing MNP in this age group, two questions about older children were included in the household survey. There were two main outcome variables of interest in this analysis asked about children ages 2–5 years. Both questions were asking about a hypothetical purchase as no assessment was made at the time of the survey as to whether a child of 2–5 years was living in the house. The first question examined acceptability for purchasing MNP for children ages 2–5 years. The question asked “Would you be willing to purchase MNP sachets in order to give to your children 2–5 years of age?” The second variable was presence of a positive pricing attitude towards the suggested price of 150 Nepali rupees (USD $2.09 in 2011) for 60 sachets every 6 months for children ages 2–5 years. The question asked “What do you think of the price of 150 Rupees for 60 sachets if you were to purchase for your child 2–5 years of age every 6 months?” Positive pricing attitude was defined as reporting ‘Price is OK’ to the suggested price, which was based on UNICEF cost estimates for a 6 month supply of MNP sachets, not including other program costs.

The socio-demographic independent variables included in the analysis were household wealth quintile and maternal education. Predictor variables of program exposure and experiences included knowledge of any benefits of MNP intake (i.e. increased appetite, increased energy or activity, increased immunity, mental development, physical growth, makes child healthy, or makes child stronger), perception of any barriers to MNP intake (included broad categories of: adverse effects on child, difficulty with preparation or serving food with MNP, lack of knowledge about MNP, lack of family support, or lack of available MNP product or accessible distribution facility), perceived access to MNP, any consumption of MNP by the 6–23 month child, receiving information and counselling from health workers or community volunteers about MNP, and hearing radio jingles about MNP. Messages provided during counselling or by radio jingle were considered a proxy for product exposure; they increased awareness, motivation and information about the product. The possible survey response options were not read to participants. Responses for program exposure factors were dichotomized to ‘yes’ or ‘no’; multiple response questions (i.e. knowledge of benefits of MNP intake and perception of any barriers to MNP intake) were required to have at least one positive response to qualify as an overall ‘yes’.

An additional independent variable of ‘batches of MNP sachets received’ was analyzed in a subset of the 15 month survey sample who were eligible to receive multiple batches of 60 MNP sachets (i.e. children ≥12 months of age). This variable was included as a factor that could influence acceptability since it represented varying durations of program exposure and experiences with MNP.

We used Chi square testing for bivariate analyses to describe how socio-demographic and program exposure factors listed above were associated with acceptability for purchasing MNP and pricing attitude. The significance level was set at 0.05.

For analysis, the data from the 3 month surveys were combined (n=1,053) and data from the 15 month surveys were combined (n=656). We chose to present data from both 3 and 15 month surveys separately since the 3 month setting reflects the perceptions and experiences shortly after intervention launch, while those respondents in the 15 month survey had longer program exposure and experience. Additionally, we were interested in examining the effect of obtaining multiple batches of MNP on acceptability of purchasing MNP, which is only applicable in the 15 month data. Those respondents who had not ever heard of MNP were not asked questions about acceptability for purchasing MNP for older children, so are not included in this analysis. The final sample sizes for these analyses were n=731 for the 3 month surveys in Rupandehi and Parsa and n=530 for the 15 month surveys in Makwanpur and Palpa. As previously described, receiving two or more batches of MNP was examined among a subset of the 15 month survey sample (n=328).

We constructed separate logistic regression models to determine associations between predictor variables of program exposure and experiences and acceptability for purchasing MNP in both the 3 and 15 month surveys. The outcome variable was reported acceptability and predictors used were only those program exposure variables found to be significant in the bivariate analyses. For each analysis, all program exposure variables were analyzed in one model because they were part of a comprehensive IYCF/MNP intervention program. We controlled for household wealth quintile and maternal education in the models. The model for 3 month survey data was also adjusted for rural/urban residence.

A de-identified dataset was analyzed using SAS 9.3 (SAS Institute Inc., Cary, NC), accounting for complex survey design. Sample weights were used when combining rural and urban areas of multiple districts for analysis.

Surveys were conducted for program monitoring of a public health intervention and did not require institutional review board approval. The Nepal Ministry of Health and Population approved the data collection. Participation in the interview was voluntary and verbal informed consent was obtained from each woman. Verbal consent was witnessed and formally recorded.

Overall, 3 months after program implementation start, 77.5% of mothers in rural and urban areas of plains districts reported they would be willing to purchase MNP for 2–5 year olds (Table 1). There were no significant differences in reported acceptability for purchasing MNP by rural/urban residence, but acceptability was positively associated with higher wealth quintile and higher maternal education. Perceiving no barriers to child MNP intake was positively associated with acceptability for purchasing MNP, as was exposure to information and counselling on MNP from a health worker or community volunteer (Table 1). When controlling for socio-demographic factors and other program exposures and experiences, mothers with no perceived barriers to child MNP intake had six times the odds of reporting acceptability for purchasing MNP compared to those with any perceived barriers (Table 2). Examples of commonly reported perceived barriers included: loose or dark stools after MNP intake, child rejecting food with MNP, child vomiting after MNP intake and lack of knowledge about MNP. Those with exposure to information and counselling from a health worker had two times the odds of reporting acceptability for purchasing MNP compared to those without exposure. Mothers exposed to information and counselling from a community volunteer did not have increased odds of acceptability for purchasing MNP compared to those without exposure, when controlling for socio-demographics.

Overall, in rural areas of hills districts 15 months after intervention start, 86.1% of mothers reported acceptability for purchasing MNP for 2–5 year olds (Table 1). Acceptability was significantly and positively associated with higher wealth quintile and higher maternal education. Acceptability for purchasing MNP was also associated with knowledge of any benefits of MNP intake, not perceiving barriers to MNP intake, perceiving that MNP were accessible, consumption of MNP, and hearing the radio jingle about MNP (Table 1). Among participants with children eligible to receive more than one batch of MNP (≥12 months of age), those who received two or more batches of 60 sachets of MNP vs. only one batch had a significantly higher prevalence of reported acceptability (94.3% vs 80.7%, respectively; p<0.01 (data not shown)).

When controlling for socio-demographic factors and other program exposures and experiences, those with knowledge of any benefits of MNP intake had almost three times the odds of reporting acceptability for purchasing MNP compared to mothers with no knowledge of any benefits (Table 3). In the same model, mothers with no perceived barriers to MNP intake also had three times the odds of reporting acceptability compared to mothers who perceived any barriers. Perceived access to MNP or maternal report of any child consumption of MNP did not have significant associations with reported acceptability for purchasing MNP when controlling for socio-demographics and other program exposures.

Overall, 66.3% of mothers in plains districts 3 months after program implementation started reported that the suggested price of 150 Nepali Rupees for a 6 month supply of MNP was ok, with few reporting the price was too low (Table 4). Positive pricing attitude increased significantly with higher wealth quintile, higher maternal education and urban residence.

In hills districts 15 months after intervention start, 73.4% of mothers overall reported the suggested price was acceptable (Table 4). No significant difference was seen in pricing attitude by wealth quintile, but positive pricing attitude increased significantly with higher maternal education.

This analysis identified acceptance for purchasing MNP for older children 2 to 5 years in Nepal and a positive pricing attitude for paying 150 Nepali rupees for 60 MNP sachets at two time points: shortly after intervention start (3 months) when project investment is usually high, and 15 months after program start where activities are more routine and may better reflect regular ongoing performance. Reported acceptability for purchasing MNP differed by socio-demographics and program exposures and experiences. Findings from this initial assessment can provide the impetus for further exploration into actual purchasing behavior for MNP in older children, which can ultimately inform future MNP distribution options in Nepal.