{
  "abstract": "Introduction Children with sickle cell anaemia (SCA) in Sub-Saharan Africa face a higher risk of malnutrition, increasing morbidity and mortality rates. We conducted a randomised controlled feasibility trial to treat children aged 5–12 years with SCA and severe acute malnutrition (body mass index Z-score <−3.0) in Kano, Nigeria (n=108). Despite high rates of ready-to-use therapeutic food (RUTF) consumption, as measured by returned RUTF sachets, suboptimal weight gain was observed, possibly due to widespread sharing of RUTF. In this ancillary study, we aimed to identify factors influencing adherence to the RUTF.Methods We conducted seven focus group discussions with 55 caregivers of trial participants in the two sites participating in the trial in Kano, Nigeria. We analysed transcripts using a hierarchical coding system and an iterative inductive-deductive approach informed by Social Cognitive Theory and the biopsychosocial model.Results An interplay between person-level and contextual factors influenced adherence to RUTF. Caregivers’ beliefs about nutrition and malnutrition changed when they saw positive changes in their child’s health, increasing their motivation to adhere to RUTF. The male head of household and cultural beliefs increased adherence to RUTF for some mothers and were a barrier to adherence for others. Barriers to adherence included financial hardship, along with cultural norms and religious practices related to communal eating and sharing food. Caregivers employed strategies to promote adherence, including modifying food preparation and food storage practices and controlling meal timing and meal participants. Some households maintained or provided more food, while others reduced it and reallocated their savings.Conclusion For older children with SCA and severe acute malnutrition living in Nigeria, social-cultural context, family dynamics and strategic modifications influence RUTF adherence. Insights from this study may guide the development of tailored strategies, family education and empowerment initiatives to enhance adherence to malnutrition interventions for children with SCA.Trial registration number SAMS trial ( NCT03634488).",
  "authors": [
    {
      "affiliations": [
        "Meharry Medical College School of Medicine, Nashville, Tennessee, USA"
      ],
      "name": "Amanda Brechko"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria"
      ],
      "name": "Shehu U Abdullahi"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria"
      ],
      "name": "Safiya Gambo"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Murtala Mohammed Specialist Hospital, Kano, Nigeria"
      ],
      "name": "Hassan Adam Murtala"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria"
      ],
      "name": "Halima Kabir"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria"
      ],
      "name": "Khadija A Shamsu"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA"
      ],
      "name": "Virginia A Stallings"
    },
    {
      "affiliations": [
        "Rodeghier Consultants, Chicago, Illinois, USA"
      ],
      "name": "Mark Rodeghier"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA",
        "Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA"
      ],
      "name": "Ahalya Ramesh"
    },
    {
      "affiliations": [
        "Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA",
        "Qualitative Research Core, Vanderbilt University Medical Center, Nashville, Tennessee, USA"
      ],
      "name": "Ashley Sellers"
    },
    {
      "affiliations": [
        "Department of Psychology, Vanderbilt University, Nashville, Tennessee, USA",
        "Qualitative Research Core, Vanderbilt University Medical Center, Nashville, Tennessee, USA"
      ],
      "name": "David G Schlundt"
    },
    {
      "affiliations": [
        "Department of Pediatrics, Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA",
        "Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA"
      ],
      "name": "Michael R DeBaun"
    },
    {
      "affiliations": [
        "Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA",
        "Department of Pediatrics, D. Brent Polk Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee, USA"
      ],
      "name": "Lauren J Klein"
    }
  ],
  "title": "Adherence to ready-to-use therapeutic food in older children with sickle cell anaemia and severe acute malnutrition: a mixed-methods study in a low-income setting",
  "uid": "3dc1ce7f-5d5b-58fa-a9a8-7cfc1b819aac"
}