A qualitative study of stakeholders and beneficiaries perspective on community-based mobile nutrition services in Gombe state of Nigeria

Abstract

Malnutrition (stunting, wasting, and micronutrient deficiencies) remain a public health challenge in northern Nigeria, particularly in hard-to-reach areas where access to nutrition services is limited. This study explored the perceptions of beneficiaries and stakeholders regarding the implementation of a community-based mobile nutrition service program in Gombe State, Nigeria, identifying successes, challenges, and opportunities for improvement. Over a three-month period, we conducted five focus group discussions (FGDs) with 30 pregnant women and mothers of children under five who were beneficiaries of the program and had consistently participated in at least three mobile nutrition service visits over the preceding six months. Additionally, we held 15 key informant interviews (KIIs) with health workers, traditional leaders, religious leaders, nutrition officers, and program implementers. Data were analyzed using thematic analysis following Braun and Clarke’s framework. A conceptual model was developed to illustrate the pathways linking implementation factors to perceived health outcomes. Beneficiaries and stakeholders perceived that mobile nutrition services improved access to care by reducing travel needs, which in turn they reported decreased hospital visits and enhanced maternal and child health outcomes. Specific perceived improvements included reduced anemia-related complications during childbirth and improved child growth following micronutrient supplementation. However, challenges such as infrequent service delivery (quarterly visits), poor road conditions limiting outreach, and cultural and language barriers constrained service effectiveness in some communities. Stakeholders emphasized the need for more frequent visits, improved logistical support, and culturally adapted communication strategies. Mobile nutrition services are positively perceived by beneficiaries and stakeholders as effective in improving maternal and child health in hard-to-reach communities. To enhance sustainability, program implementers should consider increasing service frequency, addressing logistical barriers, and incorporating culturally and linguistically appropriate approaches. These findings have important implications for scaling community-based nutrition programs in resource-limited settings.

Introduction

Malnutrition among children under five and pregnant women remains a major public health concern in Nigeria, contributing substantially to morbidity and mortality among young children^1,2, poor developmental outcomes³, and adverse pregnancy outcomes including preeclampsia⁴, postpartum hemorrhage⁵, and low birth weight⁶. Children under five are particularly vulnerable to stunting, wasting, micronutrient deficiencies¹, and recurrent infections⁷, while pregnant women frequently experience anaemia and poor nutritional status that negatively affect maternal and neonatal health outcomes⁸.

Recent report from the Nigeria Demographic and Health Survey (NDHS) 2024 reveal persistently high levels of undernutrition among children aged 6–59 months nationally, where 40% are stunted, 8% are wasted, and 27% are underweight. The survey also found that 60% of children and 50% of pregnant women have anaemia⁵. The National Food Consumption and Micronutrient Survey (NFCMS) 2021 further documented widespread micronutrient deficiencies; where among children aged 6–59 months, 31% had anaemia, 54% had vitamin A deficiency, 35% had zinc deficiency, and 63% had inadequate folate intake; and among pregnant women, 32% had anaemia, 22% had vitamin A deficiency, 26% had iron deficiency, and 85% had red blood cell folate deficiency⁹. These surveys also highlight poor infant and young child feeding practices across the country, reinforcing the continuing burden of maternal and child malnutrition in Nigeria.

The burden of malnutrition is disproportionately higher in northern Nigeria, where stunting rates approach 50%, and the highest concentrations of undernutrition are found in the northeastern and northwestern regions^10,11. Previous studies have consistently shown that northern Nigeria records higher rates of stunting, wasting, food insecurity, childhood illnesses, and poor maternal nutrition compared to southern regions^12,13. This situation has been linked to multiple interrelated factors including poverty, low maternal education, poor dietary diversity^14–16, suboptimal breastfeeding and complementary feeding practices^15,17, inadequate healthcare access, recurrent infections such as diarrhoeal diseases and malaria⁷, poor water, sanitation and hygiene (WASH) conditions¹⁸, insecurity¹⁹, and population displacement²⁰. These conditions collectively contribute to persistent nutritional vulnerability among both children and pregnant women in the region.

Gombe State, located in northeastern Nigeria, experiences a particularly severe burden of malnutrition and household food insecurity. According to the 2024 NDHS, 51% of children under five in Gombe are stunted⁵. The 2021 Multiple Indicator Cluster Survey (MICS) further reveals that exclusive breastfeeding in Gombe is only 30.7%, only 22.5% of children aged 6–23 months receive a minimum acceptable diet, and just 8.4% achieve minimum dietary diversity²¹. The NDHS 2024 also indicates that only 51% of households in Gombe have access to basic sanitation and 57% to basic drinking water⁵. The 2021 NFCMS similarly identified substantial micronutrient deficiencies across northeastern Nigeria⁹. Existing literature attributes these alarming rates to inadequate infant and young child feeding practices, maternal undernutrition, poverty, poor healthcare access, recurrent childhood infections, poor WASH conditions, food insecurity, and displacement-related vulnerabilities^22,23. These challenges are often more severe in hard-to-reach and underserved communities, where access to essential maternal and child nutrition services remains extremely limited.

To address the growing burden of malnutrition among vulnerable populations, several nutrition-focused interventions have been implemented across Nigeria, including in Gombe State. One such intervention is the Accelerating Nutrition Results in Nigeria (ANRiN) project, a state-led, World Bank-funded performance-based initiative designed to improve access to essential nutrition services for pregnant and lactating women, adolescent girls, and children under five years. Between December 2021 and December 2024, the project delivered a Basic Package of Nutrition Services (BPNS) through mobile nutrition teams operating in hard-to-reach communities in Gombe State. The package included iron-folic acid (IFA) supplementation for pregnant women, vitamin A supplementation (VAS) for children aged 6–59 months, infant and young child feeding (IYCF) counselling, micronutrient supplementation (including multiple micronutrient powders for children 6–23 months), as well as deworming (albendazole), growth monitoring, malaria prevention services, and referral support for maternal and child healthcare services. Despite the potential benefits of such mobile interventions, implementation challenges including transportation difficulties, poor road infrastructure, sociocultural barriers, insecurity, and health system limitations continue to affect programme delivery and utilization²⁴.

In health programming, the perspectives of beneficiaries and stakeholders are crucial for shaping intervention design, acceptability, effectiveness, and sustainability^25,26. While quantitative evaluations of nutrition programmes are relatively common, qualitative evidence exploring lived experiences and contextual realities in hard-to-reach communities remains limited. Studies from similar settings illustrate this gap. In Senegal, community leaders acknowledged the benefits of community-based maternal and neonatal health services but identified challenges related to drug shortages and inadequate workforce incentives²⁵. In Uganda, misconceptions regarding malaria prevention and disruptions during the COVID-19 pandemic affected uptake of maternal and child health interventions²⁷. In Kenya, perceptions of trust, empathy, respect, and accountability influenced utilisation of maternity services²⁸. These studies demonstrate that programme success in resource-constrained settings depends not only on service availability but also on how interventions are experienced and perceived within local contexts.

To address these gaps, this study examined four research questions:

1. What are the perceptions of beneficiaries regarding the accessibility and effectiveness of mobile nutrition services in hard-to-reach communities in Gombe State?

2. How do stakeholders perceive the impact and challenges of implementing mobile nutrition services?

3. What are the key barriers to delivery and utilization of these services?

4. What recommendations can beneficiaries and stakeholders provide to improve sustainability and effectiveness?

Answering these questions will provide contextually relevant insights to inform the strengthening, adaptation, and sustainability of mobile nutrition interventions in hard-to-reach communities. A conceptual framework emerging from the findings guides the analysis and is presented in the results section.

Materials and methods

Study setting

This study was conducted in Dukku Local Government Area (LGA), located in the northern part of Gombe State, Nigeria, with Dukku town as its administrative capital (Fig. 1). The LGA has a population of 207,190 and spans a land mass of 3,815 km², bordered to the north and west by the Gongola River²⁹. The dominant ethnic group is Fulani, and the primary languages spoken are Fulfulde and Hausa. The majority of the population practices Islam, with a small Christian minority.

Fig. 1.

Map of Gombe State showing the study LGA.

The study focused on seven out of the 18 hard-to-reach (HTR) communities across six wards, randomly selected to represent diverse implementation contexts for the ANRiN mobile nutrition services, and to capture the varied experiences of both beneficiaries and stakeholders. These communities are characterized by geographic inaccessibility, high rates of maternal illiteracy, low immunization coverage, limited antenatal care (ANC) attendance, and low skilled birth delivery³⁰. Most households depend on subsistence farming and seasonal migration is common during farming seasons. This setting offered a valuable opportunity to explore the implementation realities of ANRiN’s mobile nutrition interventions in hard-to-reach communities typically underserved by conventional health systems.

Study design

This study employed an interpretive qualitative approach, recognizing that experiences and perceptions are socially constructed and context-dependent. We sought to understand how participants made meaning of their experiences with mobile nutrition services. A qualitative study design was employed to explore the experiences and perceptions of both service beneficiaries and key stakeholders involved in the ANRiN mobile nutrition intervention.

Participant selection

Beneficiaries for the focus group discussions (FGDs) were purposively selected from the list of ANRiN program beneficiaries who had consistently participated in at least three mobile nutrition service visits over the preceding six months, ensuring that participants had sufficient exposure to the intervention to provide meaningful feedback. Stakeholders for key informant interviews (KIIs) were purposively identified based on their direct involvement in the design, implementation, or oversight of the mobile nutrition services, including representation from each relevant stakeholder category (project implementation units, community and traditional leaders, religious leaders, health workers, community volunteers, and nutrition officers). Data collection involved five FGDs with 30 beneficiaries (six participants per FGD), comprising mothers or caregivers of children under five and pregnant women, and 15 KIIs with stakeholders. Participants did not receive any monetary remuneration for taking part in the FGDs or interviews. However, refreshments (water and snacks) were provided to all FGD participants as a courtesy, and travel reimbursements were offered to stakeholders who traveled from distant locations to attend the interviews.

Development of data collection tools

The semi-structured FGD guide was developed based on an adapted framework focusing on community perceptions, barriers to accessing nutrition services, and the overall impact of mobile nutrition interventions^31,32. The guide was designed to facilitate open discussions among beneficiaries about their experiences with ANRiN mobile nutrition services, challenges faced, and suggestions for improvement. Following the FGDs, a semi-structured interview guide was developed for the KIIs to obtain insights into operational challenges faced by stakeholders. The KII guide included questions tailored to explore implementation processes, accessibility of services, observed impact, challenges of mobile nutrition service implementation, and strategies for improving community engagement and service uptake.

Both guides were piloted with three community members and two health workers not included in the final study sample. Pilot testing assessed question clarity, flow, and cultural appropriateness. Feedback from pilot participants led to minor revisions, including simplification of technical terms and addition of probing questions to explore cultural and language barriers more deeply. Both tools were structured to include an introduction, open-ended questions, probing questions, follow-up questions, a closing message, consent, and confidentiality assurances. A sequential approach of FGDs followed by KIIs was adopted to obtain the perspectives of both beneficiaries and stakeholders following established protocols³³.

Researcher reflexivity

The research team included both external evaluators (n = 5) and program implementers (n = 3) from the ANRiN project. To minimize social desirability bias, data collectors were not involved in service delivery. Team members with implementation roles did not participate in data collection. Regular reflexivity sessions were held to discuss potential biases, particularly regarding positive perceptions of program effectiveness. The data collection process was facilitated by trained research assistants in collaboration with community volunteers (CVs) and leaders. Interviews were audio and video recorded to ensure completeness.

Language and translation process

Interviews were conducted in participants’ preferred languages (Fulfulde, Hausa, or English) by bilingual research assistants. Audio recordings were transcribed verbatim in the original language, then translated into English by the same assistants. A second team member reviewed 20% of transcripts for translation accuracy to ensure fidelity to participants’ original meanings. Discrepancies were resolved through consensus between the translator and reviewer, with a third team member consulted when agreement could not be reached. Although the questionnaires were prepared in English, the interviews were conducted in the participants’ preferred dialects.

Data analysis

Following Braun and Clarke’s six-step framework, thematic analysis was employed to analyze the data; from familiarization to theme definition and reporting^34,35. This method enabled identification of patterned meanings across datasets, offering a flexible yet rigorous approach in analyzing qualitative data³⁶. The analytic-iterative process ensured our familiarity with the data and combined both deductive and inductive strategies to generate codes, which were then synthesized into clearly defined themes³⁷. A priori codes were drawn from existing literature and interview guides (deductive), and additional codes were generated through open coding (inductive). Data saturation was achieved after the fourth FGD and the twelfth KII, when no new themes or significant information emerged from participant discussions. The remaining one FGD and three KIIs confirmed previously identified themes, with no novel insights added.

Transcripts from FGDs and KIIs were professionally transcribed using Scribie and cross-checked by the research team for accuracy. Coding and analysis were conducted using NVivo. Three team members (PU, PO, and TA) independently coded three transcripts using the initial codebook, achieving substantial inter-coder agreement (Cohen’s kappa = 0.78). Discrepancies were resolved through discussion, and final themes were collaboratively refined. For clarity and coherence, themes were later organized under three overarching domains: (i) service accessibility, (ii) perceived impact, and (iii) barriers to service utilization. The grounded theory constant comparative method was applied to identify conceptual patterns across groups and ensure internal consistency^38,39.

Results

Participant characteristics

Participants included 30 female beneficiaries (mean age 28.4 years, range 18–42) comprising 18 mothers of children under five and 12 pregnant women. Among beneficiaries, 24 (80%) had no formal education. Stakeholders (n = 15) included 5 community health workers, 4 traditional leaders, 2 religious leaders, 2 nutrition officers, and 2 program implementation unit officers. Participants were drawn from seven communities within the ANRiN mobile nutrition service coverage area in Dukku LGA, Gombe State. Table 1 presents the demographic characteristics of all study participants.

Table 1.

Participant characteristics.

Category	Characteristic	n (%)
Beneficiaries (n = 30)	Mean age (years)	28.4 (range 18–42)
	Mothers of children under five	18 (60)
	Pregnant women	12 (40)
	No formal education	24 (80)
	Primary education	4 (13)
	Secondary education	2 (7)
Stakeholders (n = 15)	Community health workers	5 (33)
	Traditional leaders	4 (27)
	Religious leaders	2 (13)
	Nutrition officers	2 (13)
	Program implementation unit officers	2 (13)

Through our analysis, three primary domains were identified to capture participants’ perceptions of the ANRiN mobile nutrition services in HTR communities: (i) accessibility of mobile nutrition services; (ii) effectiveness/impact of mobile nutrition services; and (iii) challenges/barriers to mobile nutrition service utilization. Figure 2 shows a conceptual model summarizing the perceptions of both beneficiaries and stakeholders across these domains. These perceptions also informed participant-driven recommendations for enhancing the delivery and sustainability of mobile nutrition services under the ANRiN project.

Fig. 2.

Conceptual Model of Beneficiaries’ and Stakeholders’ Perceptions of ANRiN Mobile Nutrition Services in Hard-to-Reach Communities.

The thematic analysis yielded three primary domains, as summarized in Table 2. The findings are further presented and organized by these domains, beginning with beneficiaries’ perspectives.

Table 2.

Thematic analysis of beneficiaries’ and stakeholders’ perceptions of mobile nutrition services.

SN	Domain	Theme	Categories
1	Accessibility	Accessibility of mobile nutrition services	1. Ease of access through doorstep delivery 2. Community announcements and predictable visits
2	Effectiveness	Reduction in hospital visits	1. Decreased need for facility visits due to supplements 2. Improved management of diarrhea and malnutrition at home
		Improved maternal and child health	1. Reduced anaemia and blood transfusions during childbirth 2. Improved child growth, weight gain, and activity levels 3. Reduction in moderate acute malnutrition cases
3	Challenges	Language barriers	1. Communication difficulties when health workers lack local language proficiency 2. Improved acceptance when services are delivered in local dialects
		Delayed access	1. Long waiting times during visits 2. Infrequent service delivery (quarterly) limiting consistent access
		Cultural and religious sensitivities	1. Initial reluctance due to religious concerns 2. Need for community leader involvement to build trust
		Logistical barriers	1. Poor road conditions limiting outreach 2. Insufficient vehicles and high travel costs for volunteers

A. Beneficiaries’ perceptions of mobile nutrition service implementation

The beneficiaries described their experiences with the ANRiN mobile nutrition services in relation to accessibility, perceived effectiveness, and barriers to service utilization in HTR communities. Many reported that the services were highly accessible, as they were delivered directly to their community “doorsteps,” referring to the convenience of receiving care without the need to travel. The availability of preventive interventions was credited with reducing the need for hospital visits, particularly for children. Improvements in maternal health were also noted, including reduced reliance on blood transfusions during childbirth. However, some challenges were identified, including language barriers between health workers and community members in some areas, as well as infrequent service delivery visits, often limited to once every three months.

Accessibility of mobile nutrition interventions

Beneficiaries across all participating communities consistently expressed satisfaction with the accessibility of mobile nutrition services. Ease of access emerged as a strong recurring theme with beneficiaries stating:

“Yes, it is easy; there is no problem, we get it easily, and they always do community announcements to inform us that they will be coming.” (FGD 1/Beneficiary 1).

“It is easy to access because they brought it to our doorstep.” (FGD 3/Beneficiary 2).

“We get it once they come. They go from house to house most times, and it makes it not hard for us to get. Before, we needed to go far and use plenty of money to get these things.” (FGD 1/Beneficiary 3).

As shared by these beneficiaries, this approach reduced their physical and logistical barriers, making it easier for women and children to benefit from the interventions.

Effectiveness in improving maternal and child health and well-being

The perceived benefits of mobile nutrition interventions were overwhelmingly positive across all communities. The perceived benefits and impacts on health and well-being are sub-themed below:

I. Reduction in hospital visits: Beneficiaries reported significant improvements in both maternal and child health, particularly in terms of malnutrition prevention, disease reduction, and overall well-being. Beneficiaries noted that children were less frequently affected by malnutrition and diarrhea, which are leading causes of morbidity and mortality in low-income settings.

“It is effective because the worms in our children’s bodies are dead, leading to proper eating habits in our children.” (FGD 2/Beneficiary 4).

”My child was suffering from malnutrition, but when he started taking the powdered supplement, he started to grow, and I have not taken him to the hospital since.” (FGD 4/Beneficiary 5).

”It has reduced the rate at which we visit the hospital. The supplements are helping our children grow well.” (FGD 5/Beneficiary 2).

II. Improved maternal and child health: Improved maternal and child health outcomes were another key benefit noted by beneficiaries. Mothers shared experiences of giving birth without needing blood transfusions, a marked improvement over previous pregnancy experiences.

“Before, I had to undergo blood transfusion when I gave birth, but now I don’t, as the pregnancy drug works very well.” (FGD 2/Beneficiary 6).

”I used to undergo blood transfusions, but with this medicine, I didn’t need it anymore.” (FGD 5/Beneficiary 7).

Beneficiaries also reported noticeable health improvements in their children, particularly regarding better eating habits and weight gain, with reduced cases of moderate acute malnutrition due to child services such as deworming (albendazole), micronutrient powder supplementation and food demonstrations.

“Our children are fully active now unlike when we were not having these supplements to give them. There are many moderate acute malnourished children in the community, but now we have more nourished children since we started having these nutrition products.” (FGD 1/Beneficiary 8).

“There is really a positive impact on nutritional status of our children. Before accessing these services, there was a lot of moderate acute malnutrition in our community, but by adhering to food demonstrations, albendazole, and other child services, we have more nourished children.” (FGD 3/Beneficiary 9).

Additionally, beneficiaries noted that micronutrient powder, zinc, and ORS significantly improved the weight and overall health of their children:

“From my experience, my child was suffering from diarrhea, but when he started taking zinc/ORS, the diarrhea stopped. My child was suffering from malnutrition, but when he started taking MNP, he started to grow and gain weight.” (FGD 4/Beneficiary 10).

Challenges in accessing and utilizing mobile nutrition services

While the majority of beneficiaries found the services accessible and effective, some challenges were identified.

I. Language barriers: One identified challenge was language barriers. In some communities, beneficiaries reported difficulties communicating with health workers who were not familiar with their local language.

“The only challenge we faced is when they don’t understand our language. It made it very difficult for them to understand us and what we want to explain to them in our local language.” (FGD 1/Beneficiary 7).

However, in communities where health workers spoke the local language, respondents praised this approach, emphasizing that it facilitated better communication and acceptance of services.

II. Long waiting times during service delivery: Another challenge reported by beneficiaries was the long waiting time experienced on the day of the mobile nutrition service visit. Some beneficiaries expressed frustration about delays in the commencement of service delivery, which extended the total time they spent at the outreach location.

“When they come, sometimes we have to wait for long before they start to give us nutrition supplements and products for both children and pregnant women. It affects us, as we end up sitting down for a long time. Although they try to provide good places for us to sit to avoid sun.” (FGD 2/Beneficiary 6).

Recommendations for improving service delivery and sustainability

Based on feedback from beneficiaries, several recommendations for improving the delivery and sustainability of mobile nutrition interventions were suggested.

I. More frequent visits: There was a clear call for more frequent visits, with beneficiaries suggesting that monthly visits would better meet their needs, especially for pregnant women and young children.

“Normally, the services reach us every three months. This hinders access, especially for pregnant women in later trimesters. If it were monthly, we would have full access and have more supplements and products.” (FGD 5/Beneficiary 3).

II. Cultural sensitivity and local language support: Beneficiaries emphasized the importance of health workers who can communicate effectively in their local language and understand their cultural practices.

“The only challenge we faced is when they don’t understand our language. Maybe they can help us with people who can understand us and what we say and feel.” (FGD 4/Beneficiary 10).

”Cultural relevance ensures that the content is culturally appropriate and tailored to the specific dietary habits and health beliefs of our people. Therefore, I suggest that is considered in talking to us.” (FGD 3/Beneficiary 9).

III. Empowerment programs and community engagement: Beneficiaries emphasized the need for empowerment programs to accompany health interventions, expressing a desire for financial and material support to sustain health improvements. Additionally, they highlighted the importance of involving traditional and community leaders in the distribution of nutrition products to build trust and ensure acceptance of the services.

“Empower us with inputs to support our financial needs. By supporting us financially, we can better feed our children and maintain good health.” (FGD 3/Beneficiary 5).

”They should involve the traditional leader and community members; it will be good that they control the giving out of the things. It will make them have more trust in the giving out of the nutrition products.” (FGD 4/Beneficiary 6).

B. Stakeholders’ perceptions of mobile nutrition service implementation

The effectiveness of mobile nutrition interventions was also assessed through the lens of key stakeholders, including community leaders, religious leaders, community health workers, nutrition officers, and program implementation unit officers. The interviews contextualized the accessibility, challenges, and impact of these interventions while providing actionable recommendations for enhancing and sustaining service delivery.

Accessibility of mobile nutrition interventions

Access to mobile nutrition services was a key area of discussion across all communities. The consensus was that services were brought directly to the community, reducing barriers to care. Stakeholders noted that communities were pre-informed of visits, enabling them to mobilize members effectively.

“They usually inform us when they will come and we make announcements around the quarters in the communities that they will be visiting. They come when they say they will, and the mothers know when to attend the sessions for themselves and their children.” (KII/Stakeholder 1).

Effectiveness in improving maternal and child health and well-being

Stakeholders unanimously agreed that mobile nutrition services significantly improved child health and maternal well-being. Community health workers reported significant improvements in child health, particularly among those under five years of age, with decreased hospital visits and fewer cases of severe bleeding during childbirth.

“Before the mobile nutrition services, we had many cases of underweight children. Now, most of them are growing well, and their health is better. We used to see children with swollen bellies, but since the mobile services started, that has changed.” (KII/Stakeholder 6).

“Families don’t need to come to the health centre as often because they have the supplements and know how to manage things like diarrhea at home. We have fewer cases of severe bleeding during childbirth also because the women are healthier and better nourished.” (KII/Stakeholder 2).

A community health worker pointed to a noticeable reduction in malnutrition among children, attributing this success to the use of ORS, zinc, and albendazole.

“Yes, there was a child suffering from malnutrition and diarrhea. We gave that child and the mother ORS and zinc tablet, and albendazole when they visited the first time. When they visited for the second time, the mother told us that the diarrhea had stopped and the child looks healthier.” (KII/Stakeholder 7).

Nutrition officers and program implementation officers highlighted specific examples of improved maternal and child health:

“There was one woman who was severely anaemic and needed a blood transfusion during her last pregnancy. This time, after receiving the iron supplements, she gave birth without any complications.” (KII/Stakeholder 8).

“Before, we used to see a lot of anaemia in pregnant women. Now, with the iron supplements, we are seeing fewer women needing blood transfusions during childbirth.” (KII/Stakeholder 9).

A religious leader observed visible changes in children’s health:

“I have seen the children who used to be weak and pale now running around and playing. It is because of the nutrition services.” (KII/Stakeholder 3).

Challenges in accessing and utilizing mobile nutrition services.

I. Cultural and religious sensitivities: While some communities faced minimal cultural resistance, in some areas, stakeholders stated initial reluctance from some women to accept supplements due to lack of awareness or cultural and religious beliefs.

“We had to convince some of them that receiving the nutrition services would help them during childbirth, because some of them were not even aware of this free service, while those that were aware had religious concerns. People are talking about it, and you know people have different views on the situation. It is not easy to change their mind when they believe in a cultural or religious system. But when they see it work, they will come for it.” (KII/Stakeholder 4).

”There are still some families who don’t fully understand the benefits, but with continuous engagement, we are seeing them come around.” (KII/Stakeholder 10).

Language barrier was another challenge reported by stakeholders in some communities. Stakeholders emphasized the need for health workers to communicate in local dialects to build trust and improve participation.

“We found that when the health workers spoke in our local language, people were more likely to accept the services.” (KII/Stakeholder 11).

II. Logistical barriers: Logistical barriers were a significant challenge across all communities. Stakeholders expressed frustration over the inability to reach some remote villages due to poor road conditions and lack of transportation.

“There are some villages we only visit once every three months because the roads are so bad, and we don’t have enough vehicles to visit all these communities at once, so we have to visit communities one by one.” (KII/Stakeholder 12).

”It costs too much for the volunteers to travel, and sometimes, they have to walk long distances to reach the families, and with the bad roads some communities have, it makes it very hard to go there.” (KII/Stakeholder 5).

Recommendations for improving service delivery and sustainability

I. Need for frequent visits and logistical support: Stakeholders called for more frequent service visits to ensure pregnant women and children under five have consistent access to nutritional services.

“It is not enough to come every three months. We need them more often so that the women and children can get the care they need.” (KII/Stakeholder 3).

”We need them to come more often, especially for pregnant women who are close to giving birth. I suggest two visits in three months.” (KII/Stakeholder 10).

In addition to increasing service frequency, stakeholders emphasized the need for better logistical support, particularly more vehicles and bikes, to reach remote communities.

“Without enough vehicles, we can’t reach everyone who needs help. We need more transport to cover all the areas. In my opinion, training programs cannot address our main challenge, which is transportation.” (KII/Stakeholder 6).

“Our main challenge here is bad roads. During rainy season, it becomes worse, and vehicles cannot pass through. It makes it very difficult for the health people to come here and provide these services to our people. But we plead for support; bikes can be used to bring these things to our people.” (KII/Stakeholder 11).

II. Community engagement and sensitization: Stakeholders emphasized the need for stronger community engagement, recommending that community and religious leaders be more actively involved in planning and mobilizing community members.

“If the community leaders are more involved, we can reach more families and overcome some of the cultural barriers. When the people in the community hear it from us, they are more likely to accept it.” (KII/Stakeholder 12).

”When the religious leaders and community heads are involved, people listen more. It would help increase participation.” (KII/Stakeholder 13).

III. Incentives to enhance volunteer motivation and performance: The need for incentives to motivate volunteers and health workers was recommended by stakeholders.

“If the volunteers received more support financially, they would be able to reach more people and stay motivated. So that should be considered next time.” (KII/Stakeholder 10).

”If the volunteers were given more support, such as food packages or stipends, they would be more motivated to reach all the families.” (KII/Stakeholder 11).

Notably, participants’ perceptions of accessibility directly influenced their views on effectiveness. Communities where language and cultural barriers were addressed reported higher satisfaction with services, suggesting that accessibility factors are foundational to perceived program success. The three domains (accessibility, effectiveness, and challenges) interacted dynamically: when logistical and cultural barriers were minimized, service accessibility improved, which in turn enhanced perceived effectiveness. Conversely, where language barriers or infrequent visits persisted, even well-designed interventions were perceived as less effective. This interconnectedness highlights the importance of addressing foundational access issues to maximize the impact of mobile nutrition services in hard-to-reach communities.

Discussion

This study explored the perceptions of beneficiaries and stakeholders regarding the implementation of mobile nutrition services in hard-to-reach communities in Gombe State, Nigeria. The findings provide valuable insights into the real-world experiences of those who both deliver and receive these services, highlighting successes, persistent challenges, and opportunities for improvement.

This study yielded three principal findings. First, mobile nutrition services were perceived as highly accessible and effective in reducing hospital visits and improving maternal and child health. Beneficiaries reported improvements in child growth, reduced diarrhea episodes, and fewer anaemia-related complications during childbirth. Second, persistent challenges including infrequent service delivery (quarterly visits), logistical barriers (poor roads, insufficient vehicles), and language discordance limited service uptake in some communities. Third, both beneficiaries and stakeholders recommended more frequent visits, culturally and linguistically adapted communication, integrated empowerment programs, increased community engagement, and improved logistical support to enhance sustainability.

The finding that mobile nutrition services reduced hospital visits aligns with a growing body of peer-reviewed evidence on the effectiveness of community-based child health interventions. For instance, a systematic review by Black et al. confirmed that community-based primary health care can effectively address the major causes of child mortality in resource-limited settings⁴⁰. Building on this, Integrated Community Case Management (iCCM) programmes have been shown to reduce the treatment burden on health facilities while simultaneously lowering under-five mortality in high-burden regions^41,42. Beyond acute illness management, community-based nutrition education programmes have also demonstrated significant improvements in child growth outcomes⁴³. These studies support the notion that delivering services directly to communities not only reduces the need for facility-based care but also empowers families to manage minor health issues at home.

The perceived improvement in child health outcomes, including better weight gain, reduced diarrhea, and decreased moderate acute malnutrition, echoes findings from similar mobile health initiatives. In Indonesia, a Nutritional Rangers mobile application demonstrated substantial improvements in child nutrition and maternal knowledge, leading to better feeding practices and health outcomes⁴⁴. In Bangladesh, mobile-based nutrition counselling combined with cash transfers was found feasible and acceptable for addressing nutritional deficiencies⁴⁵. In Ethiopia, nutrition education interventions positively affected diet-health-related practices and nutritional status of mothers and children⁴⁶. These convergent findings indicate the potential of mobile and community-based approaches to improve nutrition outcomes in resource-limited settings.

The perceived reduction in anaemia-related complications during childbirth, attributed to iron and folic acid supplementation, is supported by robust evidence. Finkelstein et al. found that iron supplementation significantly reduces maternal anaemia rates, with a risk ratio of 0.30 for anaemia prevalence compared to placebo⁴⁷. A quasi-experimental study further revealed a reduction in anaemia incidence from 27.8% to 7.2% following nutrition education and IFA supplementation⁴⁸. Folic acid is also essential for preventing neural tube defects and supporting foetal development, thereby reducing risks of miscarriage and premature birth⁴⁹.

The challenges identified in this study, infrequent visits, and logistical barriers are consistent with implementation experiences in other low-income settings. In Ghana, community health officers identified logistical constraints, inadequate training, and financial support as barriers to effective service delivery⁵⁰. In Bangladesh, the effectiveness of a mobile health intervention was limited by the frequency of service delivery⁴⁵. In rural Pakistan, poor road networks and transportation constraints limited the reach of mobile health services, especially in isolated villages⁵¹. Similarly, in Ethiopia, transportation delays worsened by poor infrastructure reduced the effectiveness of health interventions in rural areas⁴⁸. These parallels highlight the systemic nature of implementation challenges and the need for context-specific solutions.

Language and cultural barriers reported in this study reflect broader challenges in community-based health interventions. Mashaba et al. reported that elderly patients in rural South Africa struggled to comprehend non-communicable disease information due to language discrepancies⁵². Similarly, patients from minority language communities in Ghana faced challenges when healthcare professionals preferred dominant languages, impeding optimal care delivery⁵³. Language barriers have been linked to increased risks in patient safety and healthcare access, as seen in emergency departments where patients with limited English proficiency experienced longer wait times and lower admission rates⁵⁴. Reflecting on the observed language discordance, program implementers explained that the linguistic landscape of the study communities is complex due to migration from neighbouring states. Individuals from Bauchi and Yobe states, who primarily speak Hausa and Fulfulde dialects that differ from the locally dominant variants, have settled in some hard-to-reach areas of Gombe State. While the non-state actor (NSA) responsible for service delivery intentionally hired health workers who were indigenes of Gombe State and fluent in the dominant local language (Fulfulde), they did not anticipate the presence of these migrant populations speaking distinct dialects. This mismatch between the health workers’ language proficiency and the specific dialects spoken by some beneficiaries contributed to the communication difficulties reported in certain communities. In contrast, where no language barriers were reported, health workers and beneficiaries shared the same linguistic background, further supporting the importance of language-concordant service delivery. In communities where interpreters were available, however, there was no report of language barriers, highlighting the importance of culturally and linguistically adapted service delivery.

The conceptual model (Fig. 2) illustrates the interconnected factors shaping perceptions of mobile nutrition services. The findings support and refine this framework by demonstrating that accessibility factors, particularly language concordance, service frequency, and logistical support, directly influence perceived effectiveness. Communities where these foundational access issues were addressed reported higher satisfaction and better outcomes, while those where barriers persisted perceived services as less effective. This suggests that the pathway from service delivery to health outcomes is mediated by accessibility factors that must be addressed to maximize program impact.

Implications for strengthening mobile nutrition services

The findings offer several insights for policymakers and health program planners. The positive perceptions of mobile nutrition services among beneficiaries and stakeholders in this study suggest community acceptance and perceived benefits, which can inform program refinements and generate hypotheses for larger-scale implementation research.

A critical area for refinement concerns logistical challenges. Increasing service frequency from quarterly to monthly visits, particularly for pregnant women and young children, would ensure consistent access to supplements and health monitoring, a recommendation that aligns with evidence from similar programs where more frequent contact improved health outcomes⁵⁵. Beyond visit frequency, transportation infrastructure also requires attention. Where poor roads limit vehicle access, motorcycles have proven effective for reaching remote communities, especially during rainy seasons. This echoes findings from Starbird et al., who argued that transportation investment is a key element in sustaining community-based health programs⁵⁶.

Logistical improvements alone, however, will not resolve the language and cultural barriers identified in this study. Rather than relying solely on bilingual health workers or community interpreters, the program should integrate trained community health volunteers more effectively alongside formal health workers. Beneficiaries clearly expressed that when community members who speak the local language and understand cultural norms are involved in service delivery, trust and communication improve substantially. Instead of limiting volunteers to mobilization roles, program implementers could engage them as active participants in counselling and supplement distribution. This approach ensures that beneficiaries’ health and nutrition concerns are adequately understood and addressed, while also responding to stakeholders’ calls for better incentives to enhance volunteer motivation. These strategies are consistent with broader evidence that culturally adapted health interventions are more effective in diverse populations⁵⁷.

Extending beyond communication and logistics, the call for empowerment programs (including financial and material support) highlights the importance of addressing the broader social determinants of health. Evidence from Nigeria suggests that nutrition-sensitive social protection interventions can improve maternal and child health outcomes by enhancing healthcare utilization, food security, and nutrition practices. For example, Ezenwaka et al. found that conditional cash transfer programmes increased uptake of maternal and child health services by reducing financial barriers and improving antenatal attendance among pregnant women⁵⁸. Similarly, Eluwa et al. evaluated the unconditional cash transfer programme across six states in Nigeria (one from each geopolitical zone) and found that beneficiaries were significantly more likely than non-beneficiaries to experience little or no hunger, and children aged 0–59 months of beneficiaries were twice as likely to have at least three meals per day. Beneficiaries also consumed 20% more diverse food groups than non-beneficiaries, and women beneficiaries were four times more likely to achieve minimum dietary diversity⁵⁹. Integrating nutrition interventions with socioeconomic empowerment strategies may therefore improve the effectiveness and sustainability of community-based nutrition programmes in resource-constrained settings.

Underpinning all these recommendations is the need to strengthen collaboration between program implementers and community leaders, including traditional and religious leaders. Leaders play a crucial role in mobilizing community members and building trust in health interventions, as emphasized by both beneficiaries and stakeholders in this study. Without their engagement, even well-designed logistical, linguistic, and empowerment strategies may fail to achieve full community acceptance.

Strengths and limitations

This study has several strengths, including the inclusion of diverse stakeholder perspectives, rich qualitative data that captures lived experiences, and the development of a conceptual framework grounded in participant narratives. However, several limitations must be acknowledged. First, the qualitative design limits generalizability beyond the seven study communities. Second, social desirability bias may have influenced responses, particularly given the research team’s association with the implementing organization; we attempted to mitigate this by ensuring data collectors were not involved in service delivery and conducting regular reflexivity sessions. Third, we did not collect quantitative outcome data to validate self-reported health improvements. Fourth, the study captured perceptions at a single time point; longitudinal data would better assess sustained impact and changes over time. Despite these limitations, the findings provide meaningful insights into implementation realities of mobile nutrition services in hard-to-reach settings.

Conclusion

The ANRiN mobile nutrition service program is positively perceived by both beneficiaries and stakeholders in hard-to-reach Gombe communities. To sustain and scale these gains, implementing partners and policymakers should: (i) increase service frequency from quarterly to monthly visits, particularly for pregnant women; (ii) invest in transportation infrastructure, including motorcycles for rainy season access; (iii) recruit and train bilingual health workers or community interpreters to address language barriers; and (iv) integrate small-scale livelihood support programs to enhance families’ capacity to maintain nutritional gains. Future research should evaluate the cost-effectiveness of these adaptations and assess long-term health outcomes using mixed methods designs. These strategies are essential for achieving sustainable reductions in malnutrition and advancing health equity in underserved populations.

Author contributions

AS, DO, MA, UI, EAJr: Funding acquisition, conceptualization, supervision, writing – review & review. LM, HI, OM, IG, KLD, MJU: Project administration, Investigation, Supervision. EAJr, PU, PO, TA, EE, DOt, HO-A, VA: Conceptualization, Methodology, Investigation, Supervision, Formal analysis, Data curation, Visualization, Writing – review & editing. PU: Writing – original draft, Project administration.

Funding

This research was funded by Solina Health Limited through the Accelerating Nutrition Results in Nigeria (ANRiN) funds from the World Bank and STAT (Grant Number: TF0A7516). The World Bank and STAT did not play any role in the study design; data collection, management, analysis and interpretation; or writing of the report.

Data availability

All data supporting the findings of this study are available within the paper. However, additional data may be made available upon reasonable request to the corresponding author, with the intention of enabling the replication of methods and findings. Access to such data will be granted upon completion of a data use agreement, outlining terms such as appropriate data citation, adherence to ethical standards, protection of participant confidentiality, and restrictions on data sharing or redistribution.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval

Ethical approval for the study was obtained from the Gombe State Ministry of Health, with reference number MOH/ADM/621/V.1/494. All methods were performed in accordance with the relevant guidelines and regulations and in line with the principles of the Declaration of Helsinki. Informed consent was secured from all participants prior to data collection. Participants were informed of their right to withdraw at any time without consequence, and confidentiality was assured through anonymization of all identifying information in transcripts and reports.