A descriptive cross-sectional non-probability study was conducted between January 2024 and June 2025 in the districts of Binah, Oti, and Tandjoaré. The baseline MUAC was obtained from programmatic records, and the 41 children have paired measurements (pre/post). MUAC measurements were collected before and after supplementation.

Study setting: The evaluation took place in the districts of Tandjoaré and Oti, located in the Savanes region, and in the district of Binah, in the Kara region. These districts are among the most affected by child malnutrition. The Savanes and Kara regions, located in the far north of Togo, are particularly vulnerable due to insecurity linked to the Sahelian crisis and frequent seasonal lean periods between May and October, as shown in Figure 1. In 2024, the population was estimated at 88,117 inhabitants for Binah, 130,657 for Oti, and 145,328 for Tandjoaré. The health system operates through a pyramidal structure, with strong community participation facilitated by Community Health Workers.

Study population: Infants and young children aged 6 to 18 months enrolled in the program and their mothers/caregivers.

Inclusion criteria: Residence of at least 6 months and completion of SQ-LNS supplementation.

2.2.1. Organization of Data Collection

Data on infants and young children aged 6 - 18 months who received SQ-LNS supplementation were recorded in registers and monthly reporting forms at the time of distribution by community health workers (CHWs). During this post-intervention evaluation, CHWs assisted the survey teams in locating the mothers of beneficiary children who had received SQ-LNS and other interventions, including IYCF (Infant and Young Child Feeding) counseling, within their respective households.

Figure 1.Map of Togo showing the SQ-LNS distribution districts.

These mothers were invited either to nearby health facilities or to community gathering points, particularly during vaccination sessions conducted through outreach strategies. Survey teams traveled to these locations to carry out data collection activities, including focus group discussions.

A data extraction form was used to collect information on children aged 6 - 18 months who received SQ-LNS, drawing from various reporting tools such as registers, monthly reporting forms, and electronic databases (e.g., Kobocollect).

In addition, interviews with mothers and caregivers were conducted through focus group discussions in local languages, with the support of field supervisors or collaborators fluent in those languages. Key informants (e.g., village chiefs, community leaders) were interviewed in the official language. These discussions aimed to assess participants’ knowledge of SQ-LNS as well as the level of community ownership of the intervention. Specifically, the focus was on mothers’ and caregivers’ knowledge and practices related to SQ-LNS and IYCF, as well as the motivating factors and barriers affecting adherence to the program.

Assessment of knowledge and acceptability of SQ-LNS was conducted using a questionnaire adapted from the WHO Frequently Asked Questions (FAQ) model, which has also been used in similar studies (Adu-Afarwuah et al., 2008; Adu-Afarwuah et al., 2011; Hess et al., 2011; Phuka et al., 2011; Ashorn et al., 2015).

In total, three focus group discussions were conducted in each of the three localities, resulting in nine focus group discussions altogether. Each focus group included 8 to 12 participants, allowing for in-depth exploration of mothers’ perspectives on the intervention. In short:

Extraction of data from registers and monitoring forms;Measurement of mid-upper arm circumference (MUAC) among children present at the time of evaluation;Nine focus group discussions with mothers (n = 90);Individual interviews with community leaders and health personnel.

2.2.2. Analysis

Comparison of MUAC values before and after supplementation using the Wilcoxon test (p < 0.05). Thematic analysis was conducted for qualitative data. Data was analyzed using STATA software version 16.1. In addition to descriptive sociodemographic analysis among mothers, a qualitative analysis was conducted [10].

2.2.3. Ethical Considerations

Data collection was carried out in the three localities with authorization from the Ministry of Health. Within the communities, the objectives and purpose of the data collection were clearly explained to participants before administering questionnaires. Only individuals who provided free and informed consent were included. As for the data, they were collected and used within the framework of the pilot SQ-LNS supplementation project in Togo.

A total of 90 women were interviewed, and 41 children were measured (20 in the Kara region and 21 in the Savanes region).

The median MUAC increased from 134 mm to 148 mm after supplementation.

Kara region: 137 mm → 150 mmSavanes region: 131 mm → 145 mm

The Wilcoxon test showed a statistically significant improvement (p < 0.001), with 37 increases compared to only 2 decreases.

93% of children accepted SQ-LNS within the first few days.33% of women report their child eats the entire SQ-LNS sachet, prefers it over other foods, and won’t share it, as shown in Figure 2. 100% of families expressed willingness to continue the program.40% of women report that their child falls ill less often since taking SQ-LNS, as shown in Figure 3.Some mothers reported a decrease in breastfeeding among older children, linked to the high palatability of the product.Most women observed improvements in their child’s appetite and vitality.

Figure 2.Acceptability of SQ-LNS among children according to mothers.

Figure 3.Perceptions of surveyed women regarding SQ-LNS.

Occasional supply stock-outs.Early cessation of breastfeeding (before two years of age) among some children.Intra-household sharing of the product in certain cases.Missed appointments and low adherence among some families.

Although the effectiveness of SQ-LNS is already well established, the results observed at the operational level are consistent with those reported in randomized trials conducted in sub-Saharan Africa and South Asia. Indeed, the findings show that regular administration of SQ-LNS significantly improves certain nutritional and growth parameters, particularly MUAC, as observed in several studies [11][12].

Furthermore, the evaluation of SQ-LNS supplementation among vulnerable children provides useful evidence to document the relevance of this intervention and its potential associations with the prevention of childhood malnutrition in a context of vulnerability in Togo.

SQ-LNS supplementation has been shown in some studies to reduce the prevalence of stunting and to improve overall child growth [13][14]. The observed effects appear more pronounced in settings characterized by high food insecurity and a high prevalence of chronic malnutrition. However, measured impacts vary depending on the context, suggesting that SQ-LNS are not a universal solution but should be adapted to local needs and vulnerabilities.

In our context, it is still premature to speak of impact, given that the implementation period lasted only six months and was marked by some limitations related to adherence. Nevertheless, the observed effects are consistent with findings from previous studies. Randomized trials conducted in Ghana, Haiti, Madagascar, Burkina Faso, and Bangladesh have shown improvements in the nutritional status of children receiving SQ-LNS [14].

However, other studies, particularly in Malawi, have not demonstrated a significant effect on child growth when comparing intervention and control groups [15][16], which contrasts with our findings.

The fight against chronic malnutrition is multifactorial and requires actions across several sectors: nutrition, water, hygiene, health, and women’s education. The lack of significant results in some studies, such as in Malawi, may be explained by factors such as lack of access to safe water, high prevalence of infections, reduced usual dietary intake, and poor adherence (e.g., sharing the product with another child) [17].

Prior to implementation, acceptability testing of the product among children was not conducted.

Based on our findings, the acceptability of the product among children and their families is generally satisfactory, as observed in most countries implementing this intervention. However, two major challenges remain:

The abandonment of breastfeeding in favor of SQ-LNS poses an increased risk of malnutrition among target children. Some children aged 18 to 24 months discontinued breastfeeding and consumed only SQ-LNS. This situation was sometimes encouraged by mothers themselves, who used the opportunity to stop breastfeeding early (before two years), contrary to current recommendations.Non-adherence, sometimes linked to missed appointments, limited understanding of instructions, or supply disruptions of SQ-LNS. These factors must be considered in the design of sustainable programs, particularly through appropriate communication strategies, reliable supply systems, and strengthened community-based follow-up.

The results of this evaluation confirm the relevance of SQ-LNS, particularly in contexts of food insecurity, as a complementary transitional intervention alongside other malnutrition prevention strategies such as exclusive breastfeeding, dietary diversification, vitamin A supplementation, and WASH interventions. However, their impact is optimized when delivered through an integrated community-based approach involving trained community health workers, well-functioning health facilities, and strong social mobilization.

This study has several limitations that should be considered when interpreting the findings. The non-probabilistic cross-sectional design and the absence of a control group limit any causal inference regarding the observed changes in nutritional indicators. The small sample size of children with paired measurements (n = 41) also reduces statistical power and generalizability. In addition, the selection of children available at the time of the survey may introduce selection bias. Qualitative findings are based on self-reported information from caregivers and key informants, which may be subject to recall and social desirability bias. Finally, the relatively short implementation period (six months) does not allow assessment of long-term effects or sustainability of the intervention.