Formative research on a post-discharge monitoring program using SQ-LNS to reduce acute malnutrition relapse risk in Mali : a qualitative study

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Abstract Introduction Up to 75% of children treated for severe acute malnutrition (SAM) relapse within six months of recovery, yet evidence on post-discharge interventions remains limited. We conducted a formative assessment to understand how small-quantity lipid-based nutrient supplements (SQ-LNS) could be integrated in post-discharge care to prevent relapse. Objective This study aimed to inform whether and how a program integrating SQ-LNS into post-discharge monitoring could be implemented in Mali. Specifically, we aimed to: 1) identify barriers and enablers to post-discharge monitoring, 2) develop one or more post-discharge models based on recommendations, 3) understand the feasibility of these model(s), 4) describe acceptability of the model(s) and product, and 5) propose a final model to be piloted at larger scale. Methods This formative study comprised two iterative phases conducted between September 2024 and May 2025. In exploratory Phase One, we conducted semi-structured interviews with 12 caregivers of children with SAM and eight treatment providers, in triangulation with 13 focus groups among caregivers, health care workers (HCW’s), and supervisors. Themes included current practices, anticipated challenges, and service delivery preferences. Findings informed a confirmatory Phase Two involving four direct observations of three delivery models implemented at four sites and 13 interviews with similar participants. Textual data were coded and thematically analyzed using Dedoose software. Results Although national guidelines recommend routine post-discharge monitoring for SAM children, it was rarely practiced due to limited awareness among HCW’s. Both caregivers and HCW’s supported the idea of post-SAM monitoring, preferring on-site over home visits for feasibility. Caregivers valued growth monitoring, interacting with HCW’s, and nutritional supplementation. While unfamiliar with SQ-LNS, caregivers viewed it positively based on their experience with therapeutic foods. Three delivery models were tested: (1) weekly visits for one month transitioning to fortnightly thereafter, (2) fortnightly visits and program days, and (3) fortnightly visits for caregivers and weekly program days at the health site. Model three proved most feasible for caregivers and providers. Conclusion This formative research informed a program design that aligns with caregiver preferences and health system capacity, requiring minimal external support. Fortnightly post-discharge monitoring paired with SQ-LNS supplementation at treatment sites is recommended.