Table 3 Integrated Egg Intervention recommendations synthesized from the PEXs and the Frameworks and Narratives for East Lombok (Indonesia) and Kaffrine (Senegal). Where elements of the recommendation are derived from Major Cultural Themes, this has been noted as Cultural recommendation, highlighted in bold

Attitudes to accepting outside help

Culture-based recommendation: Participants and their families should be provided with plentiful culturally relevant information resources for them to learn about stunting and healthy nutrition, in order to encourage menu changes.

Fathers should be engaged with early in order to increase the likelihood that they will allow for their wives to participate. Men of influence in the community such as Islamic leaders could be asked to help with this level of engagement to increase trust and likelihood of agreement to participate by men.

The Government could raise its profile as a supporter of nutrition or be invited/contacted to collaborate in messaging dissemination.

The Egg Intervention might need to have eggs consumed in presence of health worker (and thus pre-prepared) to ensure it is not stored for later or other use.

Traditional gender roles

Culture-based recommendation: Within the egg intervention, researchers should consider how to include the entire family in the intervention in terms of education/engagement and messaging or offer opportunities for networking within the community such as group meetings or peer support.

Fathers and grandmother MUST be engaged with prior to recruitment of women, as they must first agree to the participation of the mother.

Culture-based recommendation: As the ability to work and generate income was so crucial to survival of the family, the father of the family may often be away from the house and therefore difficult to contact. It is important to visit farms and markets to make contact and disseminate information to fathers in the community.

Social hierarchies

Culture-based recommendation: Islamic leaders should be included/involved in the recruitment and dissemination of information regarding the egg intervention.

Culture-based recommendation: Due to the strong value of togetherness in the community and the desire to have women’s networks it would improve the cultural appropriacy if an intervention involved all the family or had an element of group interaction for example breastfeeding support groups for women.

Culture-based recommendation: Islamic leaders should be included/involved in the recruitment and dissemination of information regarding the egg intervention.

Fathers and grandmother MUST be engaged with prior to recruitment of women, as they must first agree to the participation of the mother.

Food sharing

Specific messaging about how the egg should be prepared and potential problems with sharing should be disseminated in order to encourage the consumption of the egg by the mother.

Egg consumption may need to be supervised by a community health worker to ensure it is consumed by the participant.

Additional support could be provided such as information leaflets for additional family members.

Specific messaging about how the egg should be prepared and the problems with sharing should be disseminated in order to encourage the consumption of the egg by the mother.

Egg consumption may need to be supervised by a community health worker to ensure it is consumed by the mother.

Additional support could be provided such as information leaflets for additional family members.

Traditional beliefs about malnutrition

Culture-based recommendation: Interventions should provide plentiful culturally appropriate messaging about undernutrition and stunting with nutritional advice taking into account cultural diets and limitations of affordability of certain foods. Interventions to improve infant and child feeding practices should offer support to breastfeeding mothers, perhaps through group education sessions with lactation consultants.

The intervention should include an element of education so that families with affected children can learn the determinants/risk factors for stunting and the impacts of traditional beliefs can be mitigated. Engagement should include both grandmothers and mothers.

Pregnancy beliefs

Culture-based recommendation: Notice should be taken of unmarried pregnant women within the community who may face stigma and be less likely to approach providers of an intervention. Encouragement of participation could be carried out through community outreach.

Notice should be taken young pregnant women, or women with young children within the community (close pregnancies) who may face stigma and be less likely to approach providers of an intervention. Encouragement of participation should be carried out through appropriate community outreach.

Messaging and communications within the information provided should address misperceptions around healthy foods for pregnant women related to traditional beliefs.

Engagement should include both grandmothers and mothers.

Specific views on eggs

The intervention should take into account the perception of eggs as a healthy food, and that they are already commonly used. It must be emphasised to mothers that the supplemented egg is additional to their existing diet.

The intervention should include an element of educational messaging to dispel misperceptions around the consequences of eating eggs while pregnant and inform participants of the benefits of consuming eggs. Since this belief is traditional, this education should include older family members such as those grandmothers who have power over the decision-making in the family.

Other – food practices

Culture-based recommendation: Due to the communal meal being cooked and then eaten throughout the day – note must be taken of the likelihood of food sharing.

Specific messaging about how the egg should be prepared and the problems with sharing should be disseminated.

Egg consumption may need to be supervised by a community health worker to ensure it is consumed by the participant. This should be handled sensitively with guidance from local researchers.

Culture-based recommendation: Due to the communal nature of mealtimes, notice must be taken of sharing and that the patriarch may take food first.

Messaging should encourage mothers to eat the supplemented egg themselves and emphasise that this should not be shared.

Egg consumption may need to be supervised by a community health worker to ensure it is consumed by the participant. This should be handled sensitively with guidance from local researchers.

Other – Access to health services

Mitigate access challenges with home visits.

Culture-based recommendation: Fathers should be engaged with early, in order to increase the likelihood that they will allow for their wives to participate. Men of influence in the community such as Islamic leaders could be asked to help with this level of engagement to increase trust and likelihood of agreement to participate by men.