**Background:** There is global consensus on integrating nutrition actions into service delivery across policy sectors to sustainably reduce malnutrition. However, significant discrepancies exist between adopted nutrition policies and actual service delivery on the ground. Uganda loses approximately 5.6% of annual gross domestic product due to undernutrition. Despite childhood stunting decreasing to 29%, regional variations range between 14% and 41%. Uganda has endorsed integrated nutrition strategies (INSs) since 1996, making it a relevant case to examine how integrative demands are enacted or impeded by frontline workers—employees who interact directly with citizens and exercise wide discretion over service allocation. This study applies a street-level bureaucracy (SLB) perspective to investigate what practices frontline workers adopt to either enact or impede nutrition integration during service delivery, and the contextual conditions that galvanize these practices.
**Methods:** This qualitative exploratory study was conducted in two Ugandan districts—Moroto (stunting rate 33%, with substantial donor investment) and Namutumba (stunting rate 28%, relying mostly on government funding). The primary respondents comprised 45 frontline workers from the departments of health, agriculture, and community development across all sub-counties in both districts (22 in Moroto: 12 health workers, 5 agriculture extension workers [AEWs], 5 community development officers [CDOs]; 23 in Namutumba: 14 health workers, 4 AEWs, 5 CDOs). Additionally, 26 sub-county and district management officials and NGO nutrition staff were interviewed, totaling 71 respondents. Open-ended interviews were conducted between February and June 2018 at respondents' workplaces, focusing on four areas: understanding of malnutrition, job descriptions including nutrition actions, individual experiences providing nutrition services, and nutrition-associated work demands and resources. Data were analyzed using Atlas.ti through iterative coding based on three thematic sensitizing ideas—nutrition actions, conditions, and practices—derived from SLB theory. Practices were identified abductively by comparing empirical descriptions with theorized implementation literature.
**Key Results:** Frontline workers perceived nutrition services primarily as activities stemming from explicit donor or government nutrition projects, though their daily activities often included nutrition-specific and nutrition-sensitive actions they did not always recognize as nutrition-related. Health workers provided the most nutrition services; AEWs and CDOs expressed uncertainty about their nutrition roles. Nine co-existing practices were identified that shape nutrition service delivery. Integrative practices included: (1) ritualizing task performance—following standardized procedures for managing acute malnutrition, driven by ministry guidelines and NGO monitoring; (2) bundling nutrition actions with established services—leveraging existing programs like immunization and HIV services, predominantly in Moroto; (3) scheduling services on a specific day—offering outpatient therapeutic care on Thursdays in Moroto to focus resources and prevent supply misappropriation; and (4) piggybacking on other actors' services—AEWs and CDOs collaborating with NGOs and other departments to realize nutrition objectives despite lacking dedicated nutrition budgets. Disintegrative practices included: (5) non-involvement—CDOs and AEWs in Namutumba withdrawing from nutrition activities due to ambiguous task allocation and being sidelined in budget decisions; and (6) shifting blame—AEWs blaming procurement delays and citizen dependency for their inability to deliver services. Practices with mixed effects included: (7) creaming off citizens—prioritizing pregnant women, lactating mothers, children, and HIV/TB clients while excluding others; (8) down-prioritization by fixating on a few nutrition actions—health workers restricting assessments to stunting, wasting, and underweight while ignoring BMI and lab analyses, and incomplete administrative reporting; and (9) following the bureaucratic 'jobs worth'—health workers rigidly referring malnourished patients upward to avoid confrontation when supplies were lacking. Donor projects (UNICEF, WFP, USAID) were the primary drivers of integrative practices through technical support, directives, performance-based financing, and monitoring. Government-system institutionalization—including clear performance indicators, budgets, guidelines, and leadership—was necessary but often insufficient, particularly for AEWs and CDOs.
**Clinical Implications:** The study reveals that nutrition integration in service delivery is a dynamic, nonlinear process shaped by frontline workers' discretionary practices in response to multidimensional demands and resources. Donor-driven initiatives are essential but insufficient for sustainability; institutionalizing demands and resources within government systems is critical for maintaining services beyond timebound projects. Interventions should strengthen integrative capacities across government levels by investing in cross-sector leadership, facilitating frontline workers across health, agriculture, and community development to provide nutrition services, and adjusting nutrition monitoring systems to capture multisectoral data and support policy learning. Generating consensus around nutrition-sensitive actions with explicitly defined pathways linking them to nutrition outcomes is essential, particularly for agriculture and community development workers whose roles remain ambiguous. The findings highlight that financial incentives alone do not sustain commitment—professional collaborations, collective learning, and integrative leadership are equally important. Addressing the identified disintegrative practices requires clarifying role allocation, matching performance accountability with equivalent resources, and developing state-driven service delivery systems that can sustain nutrition integration long-term.