A realistic evaluation approach highlighted the success factors and difficulties of an innovative and comprehensive malnutrition programme in Madagascar

Malnutrition has multiple causes, not just a lack of calories. We explored the successes and barriers of an innovative, comprehensive programme in Madagascar that educated mothers in particular about nutrition.

The outpatient programme in Antananarivo treats 2400 malnourished children from 6 to 59 months each year. The 35-day programme comprises health checks, cooking demonstrations, the distribution of enriched flour supplements and two food-related games that are called Nutricartes and are based on boards and picture cards. In 2014, we involved 74 of the children's mothers in a realistic evaluation process, which investigates the mechanisms that produce a particular outcome in a given context.

The mechanisms of success were the community-based aspects of the programme, the kindness and equality displayed by the nutritional assistants and improved household budgeting and hygiene. Children ate better and improved their health, which reduced medical visits and costs. Finally, the mothers became proud of their achievements and told other mothers what they had learnt. Adherence was greatest when the women were on a minimum wage and strongly motivated.

The effect of this multifaceted programme was that the mothers received sustainable education about healthy eating and improved childhood health and nutrition.