Iterative Design, Implementation and Evaluation

of a Supplemental Feeding Program for Underweight Children

Ages 659 Months in Western Uganda
Stephanie B. Jilcott Scott B. Ickes
Alice S. Ammerman Jennifer A. Myhre
Published online: 7 February 2009
Springer Science+Business Media, LLC 2009
Abstract Objective In this paper we describe the
development, implementation, evaluation, and subsequent
improvements of a supplemental feeding program that pro-
vides community-based care to underweight children in a
rural East African setting, using a locally-sourced and pro-
duced ready-to-use food (RUF). Methods Production teams
were trained to grind soybeans and groundnuts (peanuts),
which were then mixed with moringa oleifera leaf powder to
forman energy-dense supplemental food, designed for use as
an RUF. Eligible children (based on low weight-for-age or
mid-upper-arm circumference \12 cm) received RUF of
approximately 682 kcal per day for ve weeks. Weekly
growth monitoring and caregiver education were provided
by trained health center staff and community volunteers. The
program was evaluated by examining RUF nutrient
composition, weight gain velocity, and qualitative data from
key-informant interviews and home feeding observations.
Results Locally-produced RUF had similar energy density
but higher protein content than commercial RUTF (ready-
to-use therapeutic food). Mean weight gain of children was
2.5 g/kg/day (range 0.96.0). Feeding observations revealed
that caregivers were diluting the RUF fed to children.
Production team members desired increased nancial com-
pensation for their work but were enthusiastic about the
program as helpful to malnourished children. Conclusions
Locally-produced RUF is a promising strategy for commu-
nity-based care of moderately malnourished children.
Through the production teams entrepreneurship, a small
business was formed, whereby nancial incentives encour-
aged continued RUF production. Future efforts are needed to
educate caregivers on correct RUF use and improve com-
mercial viability in local markets.
Keywords Ready-to-use food Stunting Underweight
Supplemental feeding
Introduction
Poor complementary feeding is associated with stunting and
growth faltering throughout the developing world, where
33% of children under ve are stunted [1]. Stunting (height-
for-age less than 2 standard deviations below the reference
median), is indicative of longer-term under-nutrition.
Stunting is associated with lower school achievement and
cognitive ability and thus negatively impacts development
potential [2]. As prevalence of both stunting [3] and
underweight [4] increase in Sub-Saharan Africa, innova-
tive, effective, sustainable nutrition programs are needed
to help children achieve their full growth potential.
The prevalence of stunting in Uganda is 38%, and is
S. B. Jilcott (&)
Department of Public Health, Brody School of Medicine,
East Carolina University, 1709 West Avenue, Greenville,
NC 27834, USA
e-mail: jilcotts@ecu.edu
S. B. Ickes A. S. Ammerman
Department of Nutrition, Gillings School of Global Public
Health, The University of North Carolina at Chapel Hill,
Chapel Hill, NC, USA
S. B. Ickes
e-mail: ickes@unc.edu
A. S. Ammerman
e-mail: alice_ammerman@unc.edu
J. A. Myhre
World Harvest Mission, Bundinutrition Program,
P.O. Box 1142, Bundibugyo, Uganda
e-mail: drsmyhre@yahoo.com
1 3
Matern Child Health J (2010) 14:299306
DOI 10.1007/s10995-009-0456-3
considerably worse in certain districts including Bundi-
bugyo (45%) [5], the setting for the program described in
this study.
For the purposes of this paper, complementary feeding is
dened as feeding children solids or semi-solids in com-
bination with breast milk. Supplementary feeding (SF) is
dened as provision of food by an outside entity to a
childs family, ultimately to enhance the childs nutrient
intake. SF can improve nutritional status of moderately
malnourished children [6]. SF regimens typically use cer-
eallegume mixtures that resemble indigenous staples and
are prepared as porridge using the local preparation method
[6]. The efcacy of cereal and legume-based foods in
large-scale SF programs remains inconclusive. Cereal and
legume supplements typically have a low energy density
and must be consumed in large volumes to support catch up
growth. This limitation may be overcome by the use of
protein- and energy-dense ready-to-use-therapeutic-food
(RUTF).
RUTF is an energy-dense, fortied lipid-based paste that
resists bacterial contamination, and does not require
cooking or refrigeration. Initially, RUTF was used in
emergency situations to treat acute malnutrition. However
recent SF trials have also effectively employed RUTF as a
complementary food for underweight and stunted children
[6, 7].
The high cost of imported RUTF has prompted attention
to local RUTF production [8] including development of
alternative formulations (termed ready-to-use food, RUF).
More affordable RUF is derived from local food sources,
uses locally grown foods to provide micronutrients, and
does not rely on imported milk powder [1]. Local pro-
duction efforts have focused on centralized, medium-to-
large-scale production. Although it has been suggested that
RUF can be produced in village settings with minimal
technology [9] and distributed with local labor, no such
programs have been described or evaluated. Locally-pro-
duced RUF may provide a more recognizable, affordable,
and available complementary food option, and therefore
may be more easily employed by families after discharge
from a SF program.
World Harvest Mission (WHM) is a non-governmental
organization, with a presence in Bundibugyo since 1985.
WHM and the local health center serve malnourished
children through (1) an inpatient feeding center and (2)
animal husbandry and agriculture sustainability projects,
discussed in detail elsewhere [10]. Due to the high
prevalence of stunting in Bundibugyo and documented
effectiveness of community-based care [11, 12] in 2007
WHM began a community-based SF program that provides
a locally-sourced and produced complementary food as
an RUF to underweight and stunted children ages 6
59 months. The program was designed to: (1) empower
caregivers by providing nutrition education, (2) provide
RUF and community-based care for underweight children,
(3) increase sustainability by using local food and local
health workers, and (4) increase capacity for local com-
munity groups to produce RUF as a micro enterprise. The
purpose of this paper is to describe BBB program design,
implementation, and preliminary program evaluation. We
also discuss program modications made after preliminary
evaluation.
Methods
For program implementation and preliminary evaluation,
WHM staff: (1) trained local health workers to administer
the program and provide nutrition information to caregiv-
ers, (2) identied and trained three local community groups
to produce RUF (production teams), (3) established the
two SF programs, (4) enrolled the rst two cohorts of
children, and (5) conducted qualitative interviews with
caregivers and members of production teams. The program
and data collection were approved by the Director of
District Health Services and health care staff members at
the local health centers. Eligible caregivers were intro-
duced and recruited to the program in their native language
upon arrival at the health center when children were
brought for growth monitoring. Consent for interviews was
obtained through verbal agreement at the time of the
interview, and respondents were assured that their partici-
pation in the interview would not affect care they would
normally receive.
Project Name and Logo
Indigenous speakers provided input for an appropriate
project logo and developed the program name: the Byokulia
Bisemeye Mu Bantu (BBB) Program, meaning good food
for people. A logo was designed by a Ugandan graphic
artist and used on printed shirts and ofcial program cor-
respondence (see Fig. 1). The logo was designed to convey
the role of good maternal and infant nutrition in academic
achievement in young children, the relationship between
agriculture and childrens nutrition, and the value of
educating women.
Training of Personnel
In October and November 2007, WHM staff conducted
eight nutrition trainings, held at three local health centers
for health center staff, volunteer community health
workers, and production team members, regarding: (1) the
inuence of early nutrition on school performance later
in life, (2) antenatal nutrition, (3) growth monitoring,
300 Matern Child Health J (2010) 14:299306
1 3
(4) importance of breastfeeding, (5) healthy complemen-
tary feeding, (6) responsive feeding, (7) recovery feeding
after illness, and (8) hygiene. Behavior change theory was
illustrated using the BBB of behavior change: (1)
Believe benets; (2) Break down barriers; and (3) Begin
now (goal-setting).
An average of 12 individuals attended each training
session from which eight were chosen to help administer
the BBB program. Individuals were further trained on
recruiting and screening children, enrolling eligible chil-
dren, growth monitoring, and distributing RUF.
Production Teams
WHM hired an Agriculture Extension Ofcer to procure
groundnuts (peanuts) and soybeans for local RUF produc-
tion. The Extension Ofcer identied existing womens
groups to be trainedas production teams usinghand-powered
Omega IV nut grinders (Compatible Technology Incorpo-
rated, Minneapolis, Minnesota, USA). Production teams
initially received a portion of the product as an incentive for
participation and were encouraged to use the grinders as an
income-generating project by allowing the broader com-
munity to access the machines for a small fee. The Extension
Ofcer also led efforts to construct solar dryers for incor-
poration of dried moringa oleifera leaf powder [13].
Ready-to-Use Food
The RUF was prepared by roasting groundnuts and soy-
beans in a metal pot over a charcoal re. Groundnuts were
then skinned and hand-ground. Soybeans were rst poun-
ded using the local version of a mortar and pestle and then
ground into soybean our. Moringa oleifera leaves were
mixed into the groundnut paste as they are widely available
in Bundibugyo and have high micronutrient content [14].
Caregivers brought moringa leaves to the health center
during weekly BBB program visits. Leaves were then dried
on local dryers. Production teams were given instructions
on hygiene and packaging. To assist in quality control, the
RUF was packaged in two separate bagscontaining (1)
roasted soybean our and (2) groundnut paste mixed with
moringa leaf powder, each weighing 450 g. All materials
were locally purchased. In addition to the RUF, each child
received a months supply of multivitamin, folic acid, and
iron tablets, as well as one high dose of Vitamin A and a
de-worming pill on enrollment.
Enrollment and Growth Monitoring
Screening days were announced at each health center, local
schools, and churches. Children were eligible if weight-
for-age was \the lowest line (3rd percentile line) on the
standard Ugandan immunization card (which includes a
growth chart) and/or had a mid-upper arm circumference
(MUAC) \12 cm or had been referred from the WHM
inpatient feeding program. Based on staff and food pro-
duction capacity, there was an enrollment target of 20
children. During screening, caregivers of non-eligible
children were given an explanation as to why the child was
not enrolled. If the child was eligible and the caregiver
agreed to enrollment, he/she was reminded to return each
week for education, growth monitoring, and RUF. Care-
givers were instructed to give the RUF only to the enrolled
child. The program was initially designed as a ve-week
program with participants returning once a week for care-
giver education, growth monitoring, and RUF.
Nutrient Composition
To examine the composition of the BBB food supplement,
samples of the groundnut paste and moringa powder
(without the soy our) were analyzed at the Department of
Food Science and Technology, Makerere University,
Uganda in June 2008, for moisture content (oven method),
proximate composition (crude fat, crude protein, dietary
ber and ash; AOAC, 1999 method), energy (Bomb Cal-
orimeter method), vitamin C and A (AOAC, 1999 method)
and aatoxin content (VICAM Fluorometer method).
Fig. 1 Byokuli Bisemeye mu Bantu (BBB) or good food for
people program logo
Matern Child Health J (2010) 14:299306 301
1 3
Quantitative Data Collection and Analysis
At enrollment, staff recorded weight, height, MUAC, birth
date, village, mothers name, and potentially confounding
medical details. Weight was measured to the nearest 0.1 kg
using a Salter hanging scale, length was measured to the
nearest 0.1 cm using a locally constructed standard length
board, and MUACwas measured to the nearest 0.1 cmusing
a standard measuring tape. Weights were obtained at weekly
health center visits. If a child did not return for the nal week,
the last weight recorded was used as the follow-up weight.
Birth date, village, and mothers name were obtained from
the Ugandan immunization card or the caregiver present.
Weight, age, and height data were entered into Micro-
soft Excel. Growth velocity was calculated as grams per
kilogram of weight gain per day, where the childs nal
weight (g) minus the initial weight (g) was divided by
initial weight in kilograms, which was then divided by the
number of days between initial weight and nal weight
measurements. Data were analyzed separately by health
center where the SF program was administered. Growth
velocities and standard errors were calculated using the
mean function in STATA 9.0.
Qualitative Data Collection and Analysis
A trained Ugandan interviewer uent in English and the
local language conducted in-depth interviews with the
chairpersons of two production teams to examine per-
spectives on the programs strengths and weaknesses.
These interviews were conducted without any BBB per-
sonnel present so that chairpersons would freely express
their opinions. Detailed notes were taken and reviewed by
investigators following the interviews. In addition, nine
structured caregiver interviews and home feeding obser-
vations were conducted. Interview questions are in
Table 1. Questions were translated, and responses relayed
to the investigator by the translator. Detailed eld notes
were taken. Content was analyzed for important themes
related to program improvement.
Results
Results, discussed in detail below, include (1) qualitative
interviews with production team members, (2) RUF nutri-
ent composition, (3) weight gain velocity, (4) structured
caregiver interviews and feeding observations, and (5)
program improvements made following evaluation.
Qualitative Interviews with Production Team Members
Thematic analysis of interviews with production team
chairpersons revealed that benets of being on the pro-
duction team included increased knowledge of healthy
foods to feed young children. As one member reported:
Being on the production team, we have learned how
to care for our families.
An additional benet to having a production team in
the community was an increase in community members
motivation to cultivate groundnuts and soybeans for
grinding:
It has made people work hard to grow groundnuts.
They have said this year they are going to grow
groundnuts and soybeans to begin grinding and sell-
ing them.
Reported difculties mostly related to the challenge of
grinding and lack of acceptable nancial incentives for
production. For instance, one older production team
member said:
Grinding is hard for some of us. We are becoming
old.
Regarding nancial incentives, teams noted a preference
for getting paid directly for the work instead of in-kind
compensation initially provided:
Most women want to work for money, but not work
for free
We are working for free it is making some
members leave the work.
Production teams declined an initial offer to operate as a
small business due to the perceived difculty of procuring
of raw materials. However, as production teams gained
experience in the production process, they agreed to tran-
sition their efforts into a small business. Therefore, the
program was re-designed so that teams received small
business start-up funds to purchase supplies, and then sold
Table 1 Structured interview questions for production team chair-
persons and caregivers
Production Team Chairperson Questions
What are the benets of being on this production team?
What are the difcult things about being on this production team?
Have there been problems on your team?
Does anyone from the community come to use the grinder?
Do you and your family enjoy the product?
Caregiver Questions
How do you prepare the BBB food? Please show me.
What do you enjoy about the BBB program? Tell me about that.
What is hard for you about the BBB program? Tell me about that.
Is there anything that you would like the BBB program to change
about the food you receive? Tell me about that.
302 Matern Child Health J (2010) 14:299306
1 3
the product to WHM for use in the BBB program. The
Agricultural Extension Ofcer consulted regularly with
production teams to place purchasing orders and to consult
on grinding equipment upkeep and product quality control.
RUF Nutrient Composition
Nutrient composition per 100 g of soy our, BBB peanut
paste, total BBB food supplement (combined soy our and
BBB peanut paste), commercial RUTF (Plumpynut) and
corn soy blend (common food ration in supplemental feeding
programs) is shown in Table 2. The BBB food supplement
consisted of 47% roasted peanut paste, 3% dried moringa
powder, and 50% roasted soy our, totaled 900 g, and pro-
vided the child approximately 682 kcal per day. Energy
density of the combined BBB supplement (groundnuts,
moringa, and soy our) was 5.3 kcal/g (21.5 kJ/g) and
contained 30 g of protein per 100 g supplement.
Weight Gain
Initially, there were two 5-week cycles completed at each
health center. Due to a large number of children re-quali-
fying for the program after the ve-week cycle, the program
duration was increased to ten weeks. Table 3 shows base-
line characteristics and average growth velocity for each
cycle. Growth velocities ranged from 0.9 to 6.0 g/kg/day.
Structured Caregiver Interviews and Feeding
Observations
Feeding observations revealed that most caregivers began
by peeling and boiling bananas, then adding one or two
tablespoons of groundnut paste and/or soybean our to the
sauce. A key observation made during initial feeding
observations was that caregivers prepared the BBB sup-
plement as a dilute sauce for the staple food (e.g., plantain
bananas or cassava our). To address the dilution issue, an
educational message was added to the program to promote
caregivers using a 2:1 ratio of BBB supplement to staple.
In subsequent feeding observations, it was noted that
BBB supplement components were not consumed together,
potentially affecting nutrient composition. To address this
problem, a message was added to the programs education
component encouraging caregivers to mix the groundnut
paste and soy our bags together immediately after
returning home to ensure simultaneous consumption.
Program Improvements Following Preliminary
Evaluation
In summary, preliminary BBB Program evaluation dem-
onstrated that teams desired additional nancial incentives
to continue production. Nutrient composition data revealed
that BBB supplement energy density was 5.3 kcal/g
(21.5 kJ/g), comparable to commercial RUTF (22 kJ/g).
Caregiver interviews and home feeding observations sug-
gested that the BBB supplement was not used as an RUF but
as a dilute sauce on staple foods. Table 4 is a compilation of
these programmatic issues, original program practice,
evaluation evidence for programmatic change, and resulting
programmatic changes to increase effectiveness.
Discussion
The BBB Program included several components that con-
tribute to potential sustainability and effectiveness. First,
Table 2 Comparative selective nutrient analysis per 100 g of soy our, BBB peanut paste, total BBB food supplement (soy our plus BBB
paste), commercial ready-to-use therapeutic food (Plumpynut) and USAID corn soy blend
Parameter Soy our
a
BBB paste
b
Total BBB supplement
c
Plumpynut
d
Corn soy blend
e
Total energy (kcal) 439 623 531 543 376
Crude fat (g) 21 21 21 33 7
Crude protein (g) 38 21 30 13 17
Dietary ber (g) 2 13 7 NA 9
Vitamin C (mg) 0 87 44 NA 40
Vitamin A (iu) 110 220 165 800 2612
Aatoxin content (ppb) NA 0 0 NA NA
a
Composition of Foods: Legume & Legume Products. USDA, Human Nutrition Information Service Agriculture Handbook No. 8-16
b
Nutrient analysis performed at Makerere University Department of Food Science and Technology
c
BBB food supplement consists of one 450 g bag of soy our and one 450 g bag of groundnut paste mixed with dried moringa leaf powder
d
See [6]
e
United States Agency for International Development 2006, Food Commodity Fact Sheets. 2008. http://www.usaid.gov/our_work/
humanitarian_assistance/ffp/crg/fscornsoyblend.htm.?. Accessed 20 Nov 2008
Matern Child Health J (2010) 14:299306 303
1 3
local food sources and labor were used to produce RUF,
building capacity for local womens groups to prot from
RUF production. Secondly, local health center staff and
community volunteers recruited participants, distributed
RUF, provided caregiver education, and conducted growth
monitoring. Finally, the program was improved based on
preliminary evaluation data. The current study builds on
work by others [6, 1518] by demonstrating that local RUF
production and stafng is possible in resource-limited
settings.
In the current study, although the BBB supplement
energy density was comparable to commercial RUTF,
weight gain was less than reported by others [1518]. This
may have been due to supplement dilution or sharing
among other children. If consumed as intended, the BBB
supplement could potentially provide children with over
650 kcal per day, within the range provided in SF trials
(range of 108 kcal/day/week to 1510 kcal/day/week) [19],
and similar to a Malawi-based feeding trial which provided
500 kcal/d/week of RUTF or corn-soy our [6]. In addi-
tion, the BBB program nutrition education component
emphasized responsive feeding, continued breastfeeding,
and hygienic food preparation, which are deemed to be
essential components of SF programs [20]. In the future,
the BBB supplement should be produced, packaged, and
promoted in a way that encourages caregivers to feed it to
children as RUF, similar to how one would target medicine
to a sick child [19].
Combining nutrition education about effective feeding
practices with growth monitoring has been shown effective
in promoting child growth [21]. For example, the Inte-
grated Management of Childhood Illnesses (IMCI)
program was evaluated in Brazil, wherein physicians were
trained to educate caregivers on improved feeding prac-
tices, resulting in improved feeding practices and increases
in childrens weight and height [22]. Results across com-
plementary feeding interventions indicate that in areas
with a high prevalence of food insecurity, complementary
feeding interventions that include the provision of addi-
tional food, not just education, may be most effective [20].
Among populations with sufcient food security, comple-
mentary feeding education alone increases height-for-age
z-scores by 0.25 (0.010.49) [23].
There are several limitations to the present work. First,
because this study was structured to evaluate an ongoing
program, the evaluation of the growth data was not pow-
ered to detect a particular effect and there was no control
group. Collecting growth data of children on the program
waiting list may provide a feasible control in future eval-
uations. An additional weakness is that we did not evaluate
the effect of the program on stunting, but on weight-for-
age, which is likely associated with stunting but not a direct
measure. The interpretation of growth velocities in the
BBB program (mean (SE) = 2.5 (0.6) g/kg/day) is com-
plicated by the large age range of participants, chosen to
target at-risk children. However BBB program growth
velocity was only slightly lower than results from a
Malawi-based SF trial where the mean daily weight gain
(SE) was 3.3 (3.4) g/day during RUTF supplementation
and 2.7 (3.2) g/kg/day during maize/soy our supplemen-
tation [6]. Finally, the lack of a randomized evaluation
limits the ability to determine the separate effects of the
program components.
Strengths of the BBB program include the BBB sup-
plements high energy density (531.0 kcal/100 g), similar
to that of commercial RUTF (543.5 kcal/100 g), and that
the supplement had no trace of aatoxin. An additional
strength was the use of weight-for-age criteria to enroll
children, as it is easily comprehended by local health
workers. Weight-for-age has been shown to have greater
Table 3 Characteristics and mean weight gain for children enrolled in the 5-week (cycles 1 and 2) and 10-week (cycles 35) BBB program at
Busunga and Busaru Health Centers
Health
center
Cycle Number
enrolled
Mean age
(months)
Gender
(%male)
Weight
baseline (kg)
Height
baseline (cm)
MUAC
baseline (cm)
Food supplement
dosage (kcal/kg/day)
Weight gain
(g/kg/day)
Busunga 1 21 18.5 (2.2) 40.0 6.8 (0.4) 11.5 (0.2) 105.4 (5.5) 6.0 (0.8)
Busaru 1 16 31.7 (4.5) 68.2 8.2 (0.5) 76.4 (2.5) 12.6 (2.5) 94.9 (6.5) 3.6 (1.0)
Busunga 2 16 16.7 (2.1) 52.4 6.4 (0.3) 63.7 (1.4) 11.7 (0.3) 108.8 (5.4) 3.3 (0.8)
Busaru 2 21 50.0 7.9 (0.5) 93.0 (6.5) 3.1 (1.1)
Busunga 3 25 20.0 (2.3) 41.6 6.6 (0.3) 69.0 (1.5) 11.6 (0.3) 106.4 (5.9) 1.3 (0.2)
Busaru 3 26 27.4 (2.8) 46.2 7.5 (0.3) 72.6 (1.6) 13.1 (0.3) 91.6 (4.8) 2.3 (0.5)
Busunga 4 22 13.5 (1.3) 61.1 5.8 (0.3) 62.5 (1.5) 11.9 (0.3) 120.9 (7.0) 1.7 (0.6)
Busaru 4 18 24.7 (2.8) 72.0 7.3 (0.3) 70.8 (1.5) 12.3 (0.3) 93.8 (4.1) 1.2 (0.6)
Busunga 5 25 18.7 (2.5) 32.0 6.9 (0.4) 69.3 (1.9) 12.4 (0.2) 108.1 (6.9) 1.9 (0.3)
Busaru 5 25 18.7 (3.0) 36.0 7.7 (0.6) 70.4 (2.2) 12.6 (0.4) 94.2 (7.0) 0.9 (0.3)
Values for age, weight, height, MUAC, weight gain, and supplement dosage are mean (SE)
304 Matern Child Health J (2010) 14:299306
1 3
inter-rater reliability under eld conditions and is a better
predictor of mortality versus weight-for-height [24].
In the future it will be important to examine production
team prot margin. To increase sustainability, creative
micronance initiatives are vital to improve production
team economic gain. A randomized controlled trial com-
paring SF with commercial RUTF and locally-sourced
RUF is needed not only to assess weight gain and long-
term effects on stunting, but also to assess long-term effects
on childrens diets, to determine whether participants diets
are of higher quality compared to non-participants diets.
In Bundibugyo, the BBB program is evolving to
increase the potential for long-term impact based on the
results of this preliminary program evaluation. It is our
hope that this work will help guide further systematic study
of efforts to increase SF program effectiveness and sus-
tainability in similar resource-limited areas throughout the
developing world, where one-third of children suffer from
under nutrition.
Acknowledgements We wish to acknowledge the tireless work of the
BBBWHM Agriculture Extension Ofcers, as well as health center staff
members and volunteers. We gratefully acknowledge those who spear-
headed Byokulia Bisemeye mu Bantu Project food production. We are
grateful for technical assistance from Roey Rosenblith (VillageStartup),
Jeff Rose (Full Belly Project), and Bert Rivers (Compatible Technology
Incorporated). Funding for this study was through private donations to
World Harvest Mission and through a UNC Entrepreneurial Public Ser-
vice Fellowship from the Carolina Center for Public Service at the
University of North Carolina at Chapel Hill and a grant from the Glaxo-
SmithKline UNC-Duke Student Global Health Research Project. We also
thank Dr. Archileo Kaaya, Department of Food Science and Technology,
Makerere University, Kampala, Uganda, for RUF nutrient analysis.
Authors contributions Stephanie B. Jilcott implemented the
program, collected data, analyzed data, and drafted the manuscript.
Scott B. Ickes collected data, analyzed data, and assisted in the
preparation of the manuscript. Jennifer A. Myhre conceptualized the
program, provided critical guidance and cultural insight upon pro-
gram implementation, and revised the manuscript regarding critical
intellectual content. Alice S. Ammerman helped design the qualitative
evaluation and assisted in manuscript preparation and revised the
manuscript regarding critical intellectual content. All authors have
read and approved the version of the manuscript as submitted.
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Table 4 Program operation decisions based on preliminary qualitative and quantitative program evaluation
Issue Original practice Evaluation evidence Program decision
In-kind compensation
provided to production
teams inadequate to
maintain production.
Provide production teams with
a share of the product to sell
as in-kind compensation.
Selling the product was difcult and
not worth the effort involved.
Switch to small business model
wherein WHM purchases BBB
product from production teams.
Caregivers dilute BBB
supplement with water.
Caregivers told that food ration
can be eaten directly, or used
as a sauce served with the
staple food.
Major problem with dilution of food
ration at home; food often used as
sauce on top of staple foods, rarely
eaten directly, and heavily diluted
with water during cooking.
Message added to program curriculum:
Use a 2:1 ratio of sauce:food when
preparing BBB food in combination
with starch base.
Early completion of one, but
not both food rations
before next distribution.
Soy our and groundnut paste
plus moringa mixture given
in two separate bags.
Caregivers reported that the groundnut
paste mixture was often nished
before soy our; children less likely
to enjoy soy our as stand-alone
food.
Message added to program curriculum:
Mix groundnut paste and soy our
bags together immediately after
returning home so they can always
be eaten together.
BBB supplement not always
consumed together,
affecting nutrient
composition and quality of
supplement.
Simultaneous distribution of
two separate food rations
(soy our and groundnut
paste mixed with moringa
powder).
Program may benet from a
supplement more closely resembling
an RUTF through the addition of
vegetable oil and sugar.
Educate caregivers to mix food
together at home. Decision against
adding sugar and oil to the
production process because of added
production complexity and
departure from traditional
complementary food.
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