Preparation and presentation of corn-soy blend for moderately malnourished children in Malawi
Summary of published1 and unpublished research
By Beatrice Lorge Rogers (Principal Investigator), Patrick Webb (Principal Investigator), Jocelyn Boiteau (Project Administrator), Breanne Langlois (Data Analyst), Gray Maganga (Field Research Coordinator), Shelley Walton (Project Manager) and Devika Suri (Data Manager).
The authors acknowledge that this case study is made possible by the generous support of the American people through the U.S. Agency for International Development (USAID) Office of Food for Peace of the Bureau for Democracy, Conflict and Humanitarian Assistance under the terms of the Contracts AFP-C-00-09-00016-00 and AID-OAA-C-16-00020, managed by Tufts University. The contents are the responsibility of Tufts University and its partners in the Food Aid Quality Review (FAQR) and do not necessarily reflect the views of USAID or the United States Government.
Location: Malawi
What we know: Supplementary feeding programmes (SFPs) typically involve the provision of fortified blended foods in bulk packaging for division at distribution points.
What this article adds: A recent cross-sectional study assessed the effectiveness of changes to an SFP (increased oil provision, social behaviour-change communication (SBCC) and new packaging) on caregivers compliance with recommended preparation methods of porridge. Published findings show that enhanced SBCC with an increased oil ration was the most effective and cost-effective intervention. Repackaging did not add to effectiveness but operational benefits were identified: improved hygiene; greater food safety assurance; correct amount of CSB received; and streamlined distribution/time taken. Future research on the effectiveness of repackaged food aid products is needed.
Background
According to the Malawi 2015-16 Demographic Health Survey preliminary report, 37% of children under five years old are stunted, 3% are wasted and 12% are underweight (NSO and ICF Macro, 2016). The prevention and treatment of moderate acute malnutrition (MAM) in food-insecure settings typically involves providing caregivers with supplementary foods to feed to the undernourished child (WHO, 2012). Fortified blended foods, such as corn-soy blend (CSB), prepared as a porridge, and vegetable oil fortified with vitamins A and D, are the most commonly used supplementary foods (Dewey and Adu-Afarwuah, 2008).
The Wellness and Agriculture for Life Advancement (WALA) programme 2009-2014 was a United States Agency for International Development (USAID) Office of Food for Peace integrated food security programme/supplementary feeding programme (SFP) for children with MAM in Southern Malawi. The WALA programme distributed 1L of oil and 8kg of CSB to children aged 6-59 months diagnosed with MAM at food distribution points (FDPs).
Food Aid Quality Review effectiveness study in Southern Malawi
The Food Aid Quality Review (FAQR) at Tufts University carried out a cross-sectional effectiveness study of caregivers of beneficiary children aged 6-59 months enrolled in the WALA programme in four districts in Southern Malawi from March to July 2014. Lead mothers provided health education to participants in MAM treatment programmes. Beneficiary mothers/caregivers are referred to as ‘caregivers’. The FAQR study assessed the effectiveness of programme changes on caregivers compliance with recommended preparation methods of CSB. Published findings show that enhanced SBCC with an increased oil ration was the most effective and cost-effective intervention (see Box 1). While both intervention groups were effective in achieving the target oil-to-CSB ratio, the repackaging did not result in added effectiveness. However, qualitative findings highlighted other potential benefits of the repackaging, which are shared in more detail below.
Box 1: Increasing the amount of oil used in preparing corn-soy blend porridge for treatment of moderate acute malnutrition in Malawi (Rogers et al, 2016)
CSB porridge is commonly prepared with oil for treatment of MAM. A recent review recommended that 30g of oil be used with 100g of CSB to increase energy density and micronutrient absorption (Webb et al, 2011). Some donors and implementing agencies argue that when oil is delivered as a separate commodity, it may be diverted for other uses; alternative supplements, such as ready-to-use supplementary food (RUSF), are favoured to overcome this potential risk; however such commodities are more expensive per treated child than CSB with oil given separately.
The objectives of the study were to: 1) evaluate the effectiveness and feasibility of achieving the target oil:CSB ratio in porridge prepared by caregivers; 2) evaluate the cost and cost-effectiveness of the two intervention groups compared to the control group; and 3) evaluate the determinants of effectiveness. The study also assessed the additional effect of repackaging CSB into smaller packets with printed messages to increase caregiver compliance with instructions on porridge preparation.
Caregivers of children in MAM SFPs were assigned to three groups. A control group received monthly rations of 1L oil, 8kg CSB in bulk and SBCC; intervention groups received 2.6L oil, 8kg CSB provided either in bulk (group 1) or four x 2kg packages with printed messages (group 2), and enhanced SBCC emphasising the target oil:CSB ratio.
Compared to the control, both intervention groups had higher mean added oil per 100g CSB (18g and 13g higher in groups 1 and 2, respectively), and greater odds of meeting or exceeding the target ratio (28.4 and 12.7 in groups 1 and 2, respectively). Cost per caregiver reaching the target ratio was most favourable in group 1. The cost per additional caregiver meeting or exceeding the target ratio beyond the number doing so in the control group was also most favourable in group 1. Enhanced SBCC combined with increased oil ration resulted in increased use of oil in CSB porridge in an SFP. Modified packaging did not improve effectiveness. However, both interventions were more cost-effective than standard programming.
Repackaging CSB
The rationale to investigate repackaged CSB was informed by a formative evaluation of the WALA programme that revealed challenges in the existing CSB ration distribution system (Kumwenda et al, 2016). Monthly rations of CSB were normally distributed to FDPs in 25kg sacks and the oil in 4L containers. A pre-measured 1kg capacity container was used to remove 1kg CSB.2 The remaining 24kg of CSB was poured into a large tub and given to three caregivers to sub-divide into their own containers using a spring scale (Figure 1). Some did not use the scale; for those who did, measurements were often rushed. This approach created potential for ration contamination, led to conflicts because of unequal division of the bulk CSB, and was time-consuming for caregivers and programme staff. Smaller pre-weighed and repackaged CSB were developed to address this (Figure 2).
As part of the larger study (see Box 1), semi-structured focus group discussions were conducted with caregivers. Three main themes around the smaller packaging emerged: improved hygiene to ensure food safety from production to consumption (WHO, 2006); correct amount of CSB received to prepare the ration correctly; and streamlined distribution to reduce time (see Box 2). Despite initial concerns that the more convenient packaging would promote diversion to the market, self-reported findings, complemented by visits to markets near FDPs, indicated that neither the oil nor the repackaged CSB was sold.
Although more research is needed, qualitative findings identify some potential benefits of the new packaging. The quality assurance system has set points throughout the supply chain that serve to prevent contamination of the food products. Distributed foods are marketed as safe and their quality and package integrity should be maintained throughout the entire process until the beneficiary consumes the products. Observations at FDPs demonstrated potential points of contamination of food products in bulk packaging compared to repackaged CSB. In addition, the repackaged product may increase the likelihood of the child receiving the correct ration amount and a more streamlined distribution scheme can help reduce the time burden on caregivers and distribution partners.
Box 2: Selection of focus group feedback
A caregiver commented on the added hygiene provided by the packaging, “The packets are very good because the flour is protected from a lot of unhygienic things. For example, sometimes right here at the FDP while waiting to receive the ration a child might defecate herself; while cleaning the child, your name is called to go and receive [your ration], so without even washing hands you touch the ration, so the packets protect the ration from many things.”
One lead mother recommended that the FDPs “should continue using the packet because in the past it was hard to receive the right quantity of the ration, while with the packets the women are assured that they have the right amount.”
Some caregivers reported negative feelings about the smaller packets, including that the packages were too small and should be increased in size, have too much empty space, and did not have the right amount of CSB flour. One caregiver remarked, “I am not sure if the packets have the right amount – the CSB in the packets is different from the one we used to share amongst ourselves. When we share amongst ourselves, we share equally and we are sure we get the whole eight kilograms.”
A lead mother explained what she liked about the small packaging, “Before the packets, women would spend a lot of time sharing the CSB amongst themselves but now once the vehicle arrives, they immediately receive the ration, so we can say that the packets are less time-consuming.”
Conclusions and research needs
While repackaging did not add to the effectiveness of the intervention, qualitative investigation found potential programming advantages. Future research on repackaged food aid products should evaluate effectiveness and cost-effectiveness in terms of hygiene, delivery of correct ration amounts and streamlined distribution processes. Additional field studies are ongoing to look at some priority questions raised in the overall study, particularly the cost-effectiveness of different products (CSB and RUSF) in similar settings for the prevention and treatment of MAM.
For more information, contact: Beatrice Lorge Rogers, Beatrice.rogers@tufts.edu
Endnotes
1Rogers BL, Wilner L, Maganga G, Walton S, Suri DJ, Langlois B, Chiu KKH, Boiteau J, Vosti S, Webb P. (2016). Program changes are effective and cost-effective in increasing the amount of oil used in preparing corn soy blend porridge for treatment of moderate acute malnutrition in Malawi. Matern Child Nutr. 2016; 1-10.
2After removing 1kg from eight of the 25kg bags, the CSB was used to create one complete 8kg ration.
References
National Statistical Office (NSO) and ICF Macro. (2016) Malawi Demographic and Health Survey 2015-16: Key Indicators Report. Zomba, Malawi and Rockville, Maryland, USA. https://dhsprogram.com/pubs/pdf/FR319/FR319m.pdf
WHO (2012) Supplementary foods for the management of moderate acute malnutrition in infants and children 6-59 months of age. Technical note. www.who.int/nutrition/publications/moderate_malnutrition/9789241504423/en/
Dewey KG and Adue-Afarwuah S. (2008). Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr. 2008; 4:24-85.
Webb P, Rogers BL, Rosenberg I, Scholossman N, Wanke C, Bagrianskey J, Sadler K, Johnson Q, Tilahun J, Masterson AR et al. (2011). Improving the nutritional quality of U.S. food aid: recommendations for changes to products and programs. Boston, MA: 2011. Available from http://pdf.usaid.gov/pdf_docs/pnadz841.pdf
Kumwenda G, Nlema B, Maganga G, Rogers B, Walton S, Boiteau JWP, Webb, P. (2016) Feasibility and acceptability study of preparing corn soy blend with fortified vegetable oil in Malawi: formative research. A report from the Food Aid Quality Review. Boston, MA; 2016. Available from: http://pdf.usaid.gov/pdf_docs/PA00M6CS.pdf
WHO (2006). Five keys to safer food manual. Geneva, 2006. Available from: http://www.who.int/foodsafety/publications/consumer/manual_keys.pdf
Rogers B, Maganga G, Walton S, Jayson L, Passarelli S, Suri D, Langlois B, Chui KK, Boiteau J, Ignowski E, Rosenberg I, Vosti S, Webb P. (2015) Feasibility and acceptability study of corn soy blend and fortified vegetable oil in Malawi. Report to USAID from the Food Aid Quality Review. Boston, MA, 2015. Available from: http://pdf.usaid.gov/pdf_docs/PA00M9BB.pdf
Rogers BL, Wilner LB, Maganga G, Walton SM, Suri DJ, Langlois BK, Chiu KK, Boiteau JM, Vosti SA, Webb P. (2016). Program changes are effective and cost-effective in increasing the amount of oil used in preparing corn soy blend porridge for treatment of moderate acute malnutrition in Malawi. Matern Child Nutr. 2016; 1-10.