Acceptability of a balanced energy protein (BEP) supplement for pregnant women in Bangladesh

Balanced energy protein (BEP) supplementation in pregnancy is recommended in the context of undernutrition for the reduction of small-for-gestational age neonates and stillbirths. To inform an effectiveness trial, we evaluated the acceptability of a packaged, ready-to-eat fortified BEP product among women of reproductive age and their health care providers (HCPs) in rural Bangladesh and explored the feasibility of adhering to daily supplementation. We implemented a formative study using focus groups discussions with women (n = 29) and HCPs (n = 17) to introduce the product and investigate components of acceptability. A "trials of improved practice" activity was conducted in subset of women (n = 16) to evaluate adherence to BEP over a 2-week period, followed by focus group discussions to identify challenges with adherence and strategies employed. Contributors to BEP acceptability included the product's sensory attributes, such as taste, smell and texture; the attractive packaging and informative labelling; and the perceived benefits of use. Participants also identified household and community level factors influencing the adoption of BEP, such as trust in the provider, cultural beliefs on supplement use in pregnancy, and family member tasting and approval. Over the 2-week period, women consumed over 80% of the supplements provided to them and identified strategies for adherence, including visual aids and reminders from family members or providers. HCPs recommended targeted communication messages for mothers-in-law to foster a supportive home environment. Findings informed changes to the BEP product to improve acceptability and shaped the content of communication messages to optimise adherence in a forthcoming effectiveness trial. The balanced energy protein (BEP) product introduced in this formative study was well accepted by women of reproductive age and their health care providers (HCPs), especially with regards to the overall taste, product packaging and labelling, and perceived benefits. Acceptability may be influenced by cultural beliefs around nutritional supplement use during pregnancy, and factors such as family members' approval of the product, and trust in the provider of BEP supplements.Women who consumed the product over 2 weeks had high daily adherence and identified strategies such as reminders from family members and/or providers and visual aids in the home to enhance regular use. HCPs recommended communication messages that encouraged buy in from husbands and mothers-in-law.Findings from this study informed changes to the BEP product format to improve acceptability and shaped the content of communication messages to encourage adherence in a forthcoming effectiveness trial.