Efforts to prevent and treat MAM typically rely on nutrient-dense supplementary foods, which
commonly include several variations of fortified blended foods (FBFs), combinations of FBFs with other
commodities, and ready-to-use supplementary foods (RUSFs). Corn Soy Blend (CSB) with fortified
vegetable oil is one such combination used in Title II USAID programs to treat MAM.
The Food Aid Quality Review (FAQR) is a project of Tufts University with collaboration and funding
from USAID, Food for Peace (FFP), assessing the nutritional quality of food aid products used in the
prevention and treatment of moderate acute malnutrition (MAM) in children. Phase I of the FAQR
recommended that CSB porridge for treatment of MAM be prepared and consumed with FVO (fortified
with Vitamin A and D) in the ratio of 30 g FVO to 100 g CSB (abbreviated 30:100). Phase I also
recommended providing CSB in repackaged, individual, packets with printed behavior-change messaging
giving instructions on proper preparation of the porridge. These recommendation were made with the
aim of increasing the caloric density of CSB porridge, improving the absorption of fat-soluble vitamins
through the additional FVO:CSB ratio, and improving the preparation and use CSB porridge through SBCC.
The smaller CSB packets also have the potential to streamline the distribution process and create more
hygienic CSB storage. However, the programmatic feasibility of this recommendation and the extent to
which caregivers’ cooking practices could be altered was unknown.
From July 2013 to July 2014, Tufts University conducted a repeat cross-sectional study in Southern
Malawi. This study assessed whether, and the extent to which, an increased ration of FVO, delivered
with Social and Behavior Change Communication (SBCC), could influence compliance with the
recommended target ratio (30:100) in CSB porridge prepared by beneficiary mothers/caretakers
(BMCs). The target group in this study were BMCs and the study was conducted under a MAM
treatment program in Southern Malawi. Children (children 6-59 months of age) identified as having
MAM (using mid-upper-arm circumference measurements and thresholds) in their home villages were
enrolled in the Supplementary Feeding Program (SFP), through which they received four monthly food
rations that could be retrieved at predetermined Food Distribution Points (FDPs) on announced
delivery days. BMCs with children enrolled in the SFP in 16 purposively selected FDPs across four
districts: Mulanje, Chiradzulu, Machinga and Balaka served as the sampling frame for the study. BMCs
were randomly selected from rosters for participation from within the FDPs.
This study had three main objectives: (1) assess feasibility of the interventions to increase the FVO:CSB
ratio in porridge prepared by BMCs, and assess the effectiveness of interventions to achieve that goal;
(2) determine the cost and cost-effectiveness of the interventions; and (3) assess potential determinants
of effectiveness and cost-effectiveness of the interventions.
There were three rounds of data collection: (1) Baseline; (2) Intervention 1 and Control; and (3)
Intervention1, Intervention 2 and Control. The control group received the standard, monthly Malawian SFP
ration (one L of FVO and eight kg of CSB distributed in bulk from 25-kg sacks). Intervention Group 1
received a monthly ration of 2.6 L of FVO and eight kg of CSB in bulk, along with intensified SBCC
emphasizing the importance of preparing CSB porridge at the recommended FVO:CSB ratio.
Intervention Group 2 received the same intervention as Intervention Group 1 (2.6 L FVO/month, eight
kg CSB/month with intensified SBCC), and received the CSB repackaged into two kg packets with printed behavior-change messaging giving instructions on proper preparation of the porridge. Formative
research was conducted prior to implementation of the interventions, in order to develop the SBCC
messages used in the interventions. This report contains the results of the analysis on the comparison of the
two intervention groups with the control group, based on data collected in the third round.
The primary study outcome of this study was mean FVO:CSB ratio (i.e. grams of FVO per 100 g of CSB)
in prepared porridge. Additionally, to assess compliance with the target ratio, a second primary
outcome was percentage of BMCs reaching or exceeding a FVO:CSB ratio of 30:100, as determined by
lab analysis of porridge samples taken from beneficiary households.
A total of 584 BMCs participated in this analysis: n=192 in Intervention Group 1; n=196 in Intervention
Group 2; n=196 in the Control Group. Objective I results showed that the mean FVO:CSB ratio was
significantly higher in the two intervention groups than in the control: 28:100 in Intervention Group 1;
25:100 in Intervention Group 2; 12:100 in the Control Group (p<0.001). Additionally, the proportion of
BMCs meeting or exceeding the target FVO:CSB ratio of 30:100 was significantly higher in the two
intervention groups compared to the control group (p<0.001): 37 percent in Intervention Group 1, 30
percent in Intervention Group 2 and 5 percent in the Control Group. There was no statisticallysignificant
difference in FVO:CSB ratios across the two intervention groups. Reported sharing (defined
as anyone other than the beneficiary child consuming CSB porridge) was higher in the Control Group
than the Intervention Groups. Observed sharing behavior was similar to that of reported.
Individual components included in the cost assessment (Objective II) were: commodity purchases;
international shipping and national and local transportation; warehousing; labor costs; BMC travel time
to/from FDPs; intervention-related costs (e.g. repackaging materials and labor) and pre-implementation
investments (e.g. SBCC formative research and design of CSB repackaging). The average estimated cost
per beneficiary, i.e. cost per four one-month rations distributed as programmed, was $143 US dollars in
Intervention Group 1, $158 US dollars in Intervention Group 2 and $83 US dollars in the Control
Group. Using the percentages of BMCs meeting or exceeding the target FVO:CSB ratio of 30:100 from
Objective 1, the marginal cost of one additional BMC meeting or exceeding the target ratio in
Intervention Group 1 was $188 US dollars, and in Intervention Group 2, was $300 US dollars. Overall,
these findings indicate that Intervention Group 1 was the most cost-effective of the two interventions
seeking to increase the FVO:CSB ratio in prepared porridge.
In order to assess the effectiveness of the SBCC component of the interventions, a composite score
was developed based on BMCs’ recollection of being told the following: porridge ingredients and
amounts; frequency with which to feed the children; individuals who should consume the porridge;
length of time to boil the porridge; storage of the CSB; and storage of the FVO. The composite SBCC
score ranged from zero to six, with a score of six indicating high exposure to SBCC messaging. Mean
SBCC score was 5.65, 5.67 and 5.20 in Intervention Group 1, Intervention Group 2 and the Control
Group, respectively (p<0.001, ANOVA test). There was no statistically significant difference between
the two intervention groups.
This study concludes that BMCs provided with an additional FVO ration and SBCC will, on average,
prepare porridge with a higher FVO:CSB ratio, and that significantly more BMCs will prepare porridge
that is at or above the 30:100 ratio recommended, compared with BMCs receiving standard programming. The study found no added impact on measured FVO:CSB porridge ratios when delivering
the CSB in two kg packages that contained messaging and cooking instructions. As expected, the average
cost per beneficiary was lowest for the control group, but on average FVO:CSB ratios were low and
only a small proportion of BMCs in this group were preparing porridge at or above the recommended
30:100 ratio. Increasing the amount of FVO delivered to BMCs and providing information regarding
porridge preparation increased costs, but also increased both the average FVO:CSB ratios and the
proportion of BMCs preparing porridge at or above the recommended FVO:CSB ratio. When extra
FVO and messaging were provided, repackaging CSB into smaller, message-containing packages did not
alter the FVO:CSB ratio or the proportion of BMCs reaching or exceeding the recommended FVO:CSB
ratio. While repackaging of CSB in Intervention 2 was less cost-effective in terms of increasing porridge
FVO:CSB ratio, there may be other benefits such as improved hygiene and BMC preference for
packaging. The study design did not permit measuring the separate effects of providing the additional 1.6
L of FVO or the SBCC messaging.
Changes in programming can induce BMCs to increase the average FVO:CSB ratio in the porridges they
prepare, in some cases up to or beyond recommended levels. The expected benefits of doing so in
terms of improvements in child nutrition and health remain to be measured, and these benefits should
be set alongside the marginal programming costs reported here in order to determine the wisdom of
supplying additional FVO and SBCC. Our results suggest that repackaging CSB is not successful in
influencing FVO:CSB porridge preparation ratios, although repackaging may generate other benefits that
were not measured in this study: they are more hygienic than bulk distribution; their distribution at the
FDP is more efficient and less time consuming; and some study subjects found that receiving packages
rather than having to scoop CSB from open tubs was more dignified.