1. RUTF PRODUCTS IN
RURAL CAMBODIA
The acceptability study of a novel ready-to-use
therapeutic food
Kira Anderson, MPH Candidate
Summer 2013
A study
report
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TABLE OF CONTENTS
Introduction & Background.....................................................................................................page 1
Introduction.................................................................................................................page 1
Statement of the Problem............................................................................................page 2
Background & Need....................................................................................................page 3
Purpose of the Project..................................................................................................page 5
Goals & Aims…………..............................................................................................page 6
Methods…………...........................................................................................................page 6
Research Design…………..........................................................................................page 6
Study Setting…………..............................................................................................page 6
Sampling & Participants…………..............................................................................page 6
Intervention & Materials………….............................................................................page 7
Instrumentation…………............................................................................................page 8
Data Collection…………............................................................................................page 8
Data Analysis…………..............................................................................................page 9
Results……...........................................................................................................................page 10
Discussion…….....................................................................................................................page 14
Limitations………….................................................................................................page 15
Conclusions……….................................................................................................page 15
References……..................................................................................................................page 17
Appendices……....................................................................................................................page 19
Appendix I: Survey Instrument (Khmer)..................................................................page 19
Appendix II: Survey Instrument (English)................................................................page 22
3. INTRODUCTION& BACKGROUND
Introduction
Malnutrition early in life can cause a number of problems including irreversible damage
to cognitive development, immune system, and physical growth (1,000 Days, 2013). According
to 1,000 Days, “This results in a diminished capacity to learn, poorer performance in school,
greater susceptibility to infection and disease, and a lifetime of lost earning potential” (1,000
Days, 2013).
According to a literature review of ten studies, undernutrition accounts for over 50% of
all deaths among children worldwide (Caulfield, 2004). Levels of malnutrition are high in
Cambodia; in 2010, 40% of children under age 5 were suffering from moderate to severe
stunting, while 28% were moderately to severely underweight, and 11% were experiencing
moderate to severe wasting (refer to Figure 1) (UNICEF, 2010). Among children ages 6-23
months, only 24% met the WHO’s minimum requirements for breastfeeding and complementary
feeding (National Institute of Statistics, 2011).
Figure 1 (WHO, 2012a)
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Eighty percent of Cambodia’s population is rural and 30% impoverished (UN,
2012). Because of the health risks associated with their physical, social, and economic
living conditions, rural and poor populations are at increased risk of experiencing
health issues including malnutrition. Additionally, rural Asian populations often
consume inadequate amounts of fruits and vegetables (Kanungsukkasem, 2009),
making them prone to micronutrient deficiencies.
Childhood mortality contributes to overall mortality, life expectancy, and years of
productive life lost. Children are particularly susceptible to nutritional deficiencies and various
exposures because of their small body sizes, rapid physical development, relatively high
breathing and food/water consumption rates, and unsanitary behaviors (Alliance For Healthy
Homes, 1995). Prolonged nutrient deficiency can lead to growth stunting, which is manifest in
40% of Cambodian children under age 5 (WHO, 2012a). With over one-and-a-half million
children under age 5, more than 10% of Cambodia’s population is currently at risk of
experiencing early malnutrition (UNICEF, 2012).
Statement of the Problem
Ready-to-use therapeutic food (RUTF) was developed as a treatment for severe
wasting, defined as a WHZ of -3 or more SD from the mean (Yang, 2013). Severe
wasting is often a result of acute temporary food shortages or disease (Yang, 2013).
Despite the fact the greater individual risk posed by severe wasting, the majority of
undernutrition-related morbidity and mortality is caused by mild to moderate forms of
malnutrition (WHZ or HAZ -1 to -3), which are caused by chronic undernutrition
(Yang, 2013). Mild to moderate undernutrition is more prevalent among Cambodian
children, is more difficult to reverse than severe malnutrition, and has long-term health,
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educational, and economic repercussions (UNICEF, 2010; Yang, 2013). Ready-to-use
supplementary food (RUSF) products are used to treat mild to moderate malnutrition
and to prevent acute undernutrition, providing less energy at a lower cost than RUTF
(Yang, 2013).
Background & Need
Plumpy’nut was the first RUTF, and unlike its predecessors, is packaged by individual
serving and does not require preparation (Bourdier, 2009). The product allows children to be
treated at home, thus increasing the number of children who can be treated without going to the
clinic, avoiding increased requirements for hospital staff and medical materials (Bourdier, 2009).
Plumpy’nut has been particularly successful in sub-Saharan Africa, where a number of
countries have experienced famine, drought, or long-term conflict leading to widespread acute
malnutrition (Bourdier, 2009). The situation in Cambodia, however, is vastly different, as the
country has experienced none of these problems in recent years (Bourdier, 2009). Despite the
difference in circumstances, decision-makers assumed that the presence of food insecurity in
Cambodia was enough to justify the introduction of Plumpy’nut and that existing medical and
community systems were sufficient to support implementation (Bourdier, 2009).
These assumptions proved to be incorrect. Plumpy’nut alone was provided to clinics,
with insufficient communication and no program support or follow-up, straining hospitals’ staff
and resources (Bourdier, 2009). Neither health workers nor families of malnourished children
fully understood the purpose and intended implementation of the product (Bourdier, 2009). In
some cases, instructions were poorly understood, while in others they were poorly implemented;
most families allowed the child to choose what he/she wanted to eat, as well as when and how
much to eat, as is the custom with feeding children in Cambodia (Bourdier, 2009). Additionally,
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the taste and formulation of Plumpy’nut were unfamiliar to Cambodians, and its smell and
appearance were commonly disliked (Bourdier, 2009).
The understanding of Plumpy’nut as a food-medicine was a point of confusion as well.
In Cambodia, food is considered a substance which can improve health, but not necessarily
something that can cure disease (Bourdier, 2009). After the nature of Plumpy’nut was
sufficiently explained by health staff, it was understood as a medicine which has the appearance
of food (Bourdier, 2009).
Another difficulty was insufficient comprehension of malnutrition. Many Cambodians
identify the need for food only as the temporary feeling of acute hunger, and do not recognize the
relationship between chronic food intake and body stature (Bourdier, 2009). Accordingly, it is
difficult to express the idea of undernutrition as a prolonged lack of food which affects the body
on a long-term basis (Bourdier, 2009).
Taking all of these factors into consideration, it is easy to understand how the
implementation of Plumpy’nut was unsuccessful in Cambodia. The situation with Plumpy’nut
highlighted the necessity of adequate planning in all affected sectors and the provision of
program training and support in the implementation of new RUTF products.
SCP, formerly known as CSB++, is a fortified blended food (FBF) used for
supplementary feeding (UNICEF, nd). Though the product has been adjusted to improve its
nutritional value in recent years, it still has a number of shortcomings: SCP provides only 410
kcal per 100g of dry product, which translates into a relatively small amount of energy per
serving; it does not contain enough fat; it is bulky; it requires clean water as well as time and
equipment to prepare; and after being cooked, it cannot be stored (UNICEF, nd; Pee, 2008).
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Limited information is available regarding BP100. One study in Sri Lanka showed that
BP100 was not well accepted in biscuit form (Dibari, 2013a). In another study in Afghanistan,
nearly all mothers diluted the bar by adding it to boiling water to make it into porridge
(Médécins, 2002). If BP100 is eaten in porridge form, it presents some of the same problems as
SCP: it may provide insufficient energy per serving, and requires clean water and preparation for
consumption.
EezeePaste is a fairly new RUSF product, which has not been fully researched (Wieringa,
2013). The IRD was requested to test the RUSF by an individual involved in eeZee production
(Wieringa, 2013).
Many RUTFs are produced far from where they are implemented; Plumpy’nut is
produced in France, SCP is produced in Belgium, Germany, Italy, and Kenya, BP100 is
produced in Norway, and eeZeePaste in India (Wieringa, 2013; UNICEF, nd; GC, nd).
Importing RUTFs from these places to Cambodia decreases the products’ useable shelf-life due
to the time spent in shipping, and increases costs for consumers (Wieringa, 2013). The
unsatisfactory nature of existing RUTFs justifies the need for a low-cost, locally produced RUTF
that is adapted to the taste of Southeast Asian children (Wieringa, 2013).
Purpose of the Project
HEBI was developed by the National Institute of Nutrition in Hanoi, Vietnam (Wieringa,
2013). Made largely of local products including mung bean and soya, HEBI is not only locally
produced but also has the potential to be more acceptable than Plumpy’nut and other existing
supplementary foods (Wieringa, 2013). Though acceptability and effectiveness of HEBI has
been established in Vietnam, the product must be researched in Cambodia (Wieringa, 2013).
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The purpose of this project is to determine the acceptability of HEBI in Cambodia, in
order to form the basis for further studies of the product’s effectiveness in the context of
Cambodia.
Goals & Aims
The study aims to describe the product in terms of color, smell, taste, appearance, and
texture, as well as overall appreciation of the product; in case HEBI is found to be unacceptable,
this characterization can help product developers to appropriately adjust HEBI to fit
Cambodians’ preferences.
METHODS
ResearchDesign
The HEBI study is a descriptive study of qualitative and quantitative data collected via
survey and focus group. The study was designed as per the requirements of IRD, its sponsoring
organization.
Study Setting
The study took place in six villages in the operational district (OD) of Preah Sdach in
Cambodia’s Prey Veng province. The villages were Sam Noy, Khla Kham, Troah, Svay Tol,
Mrenh, and Chey Ta.
Sampling & Participants
The local VHSG in each village was responsible for recruiting ten mother-child pairs
from his or her respective area of Prey Veng province. Participants were selected according to
their availability and willingness to participate.
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Ten mother-child pairs were recruited in each village. Inclusion criteria required the
child to be between the ages of 4 and 9. Though HEBI is intended for children between 6
months and 5 years of age, older children were surveyed to maximize the ability to verbally
express product perceptions, without compromising similarities in taste between the target
population and those being surveyed.
Prey Veng province is populated by over one million people, 76.3% of whom are
employed in agriculture, with another 15.8% in sales and services (USAID, 2008; National
Institute of Statistics, 2011). Of Cambodia’s 24 provinces, Prey Veng is ranked the 13th poorest
(USAID, 2008). Education is also low, as the median level of education completed by survey
respondents in Prey Veng was 3.9 years of school (National Institute of Statistics, 2011).
When the WHO conducted a survey in Cambodia from 2010-2011, 356 children aged 0-5
were measured for height and weight (WHO, 2012b). In Prey Veng province, 2.7% of
participants were severely wasted and 10.4% were moderately wasted (WHO, 2012b).
Intervention & Materials
The time period for the study was June 11-13, 2013. Surveys were administered by four
RACHA employees in six villages in Preah Sdach OD, Prey Veng province: Sam Noy and Khla
Kham on June 11, Troah and Svay Tol on June 12, and Mrenh and Chey Ta on June 13. Two
additional staff members helped with logistical support.
Materials used in the study included two types of RUTF: BP100 and HEBI paste; one
type of FBF: SCP; and two varieties of RUSF: HEBI bar and eeZee paste. This report refers to
these five products collectively as RUTF products. Serving trays and disposable dishes and
utensils were used to present the RUTF products to study participants.
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For measuring child participants, a height board, a digital weighing scale, and MUAC
measurement strips were used.
Instrumentation
Child height, weight, age, and gender were included in the demographics section of the
survey in order to assess WHZ scores.
Survey questions regarding RUTF products were based on Dibari’s 5-item Likert scale,
which was used in a study on the acceptability of new RUTFs among adult HIV patients in
Kenya (Dibari, 2013b). The original instrument assesses participants’ general preference of each
product as well as perception of the product’s color, taste, sweetness, and texture (Dibari,
2013b). The survey was adapted for this study to include color, taste, texture, smell, appearance,
and overall preference of each RUTF product. Sweetness was not assessed because of its
similarity to taste. Smell and appearance were deterring factors in the acceptance of Plumpy’nut
in Cambodia (Bourdier, 2009), so these qualities were included in the HEBI trial to avoid the
same issue.
Responses for closed-ended RUTF survey questions were based on Cohuet’s 5-point
Likert scale, which was used to assess children’s appreciation of RUSF products in Niger
(Cohuet, 2010). Cohuet’s scale used smiley faces to represent very bad, bad, indifferent, good,
and very good perceptions of the products (Cohuet, 2010). The rating system used in this study
was a simplified version of Cohuet’s instrument, including 3 levels of rating – bad, okay, and
good – which were indicated by corresponding emoticons.
Data Collection
Before being surveyed, children were registered with information including village,
name, and date of birth, then measured for height, weight, and MUAC. This information was
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recorded on individual surveys, with select information recorded on the village registry, which
documented all of the children surveyed at each site. Following registration, a health promotion
presentation was provided to participants. Once this was complete, mother-child pairs were
called into a separate room where surveys were administered.
Five RUTF products were presented on a tray to each mother-child pair. Children were
generally surveyed first and mothers second, excepting cases where children refused to try the
products before their mothers; in those cases, mothers were surveyed first.
Four individuals administered surveys: two employees from RACHA’s Child Health
division in Phnom Penh and two others from the Prey Veng office. All surveyors attended a
training conducted by Dr. Ketsana on Monday, June 10.
Data Analysis
Acceptability is defined as a quality that makes something attractive or satisfactory
(Marshall, 1977). This definition has been applied to this study; in this case, acceptability refers
to how well-liked the RUTF/RUSF products are. Operationally, acceptability is defined as a
composite rating of color, smell, taste, appearance, texture, and overall appreciation of the
product, as adapted from Dibari’s RUTF study (Dibari, 2013b).
Independent variables were date, interviewer, participant number, mother/child status,
village, caretaker name, age, and gender, caretaker-child relationship, and child age and gender.
Dependent variables were child weight, height, WHZ, and MUAC, as well as color, smell, taste,
appearance, texture, and overall rating, each of which was collected for the five supplementary
food products. Other dependent variables were favorite and least favorite RUTF/RUSF product.
Overall sample size was 133, including 120 recruits and 13 additional participants.
Nineteen surveys were excluded from data analysis due to incompleteness of information. The
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final sample includes 65 caretakers and 49 children, for a total sample of 114. Several questions
were each missing one response; still, rating frequency percentages were calculated based on a
total of 114 responses in order to ensure greater accuracy and reflection of the entire sample.
Each product was scored for color, smell, taste, appearance, texture, and overall rating.
Mean scores for each variable were calculated on a scale of 0-2 to represent ratings of “bad” (0),
“okay” (1) and “good” (2). For each product, the 6 variables were added to produce a total
product rating on a scale of 0-12. Product ratings were then divided by the highest possible score
(12) to yield an acceptability percent.
For reference, WHZ categories are normal weight (+1 to ≥ -2 SD), moderate acute
malnutrition (< -2 to ≥ -3 SD), and severe acute malnutrition (< -3 SD) according to the
international mean weight-for-height recommended by the WHO (UNICEF, 2011). WHZ were
analyzed to the nearest hundredth, as calculated by the WHO anthropometric calculator
(available via WHO, 2011). These categories can be used to contextualize reporting of WHZ
scores.
RESULTS
The study had a total of 133 respondents. Of those, 114 surveys were considered
sufficiently complete to be included in the analysis. Sixty-five respondents were caretakers; 62
were females and 3 were males. Caretakers’ mean age was 38.54 years (range 21-62). The
remaining 49 participants were children, 26 of whom were females and 39 males. Children’s
mean age was 6.10 years (range 4-9). The mean height for children was 108.7 cm, with a mean
weight of 16.10 kg. The average WHZ score was -1.36, and the mean MUAC 147.71 mm.
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Table 1 shows the frequencies and percentages of responses for each item included in the
survey’s product rating matrix.
15. Table 2 displays average composite ratings of product characteristics. These scores are
based on the individual ratings of each trait on a scale of 0-2. Accordingly, total product ratings,
which are comprised of the scores for all 6 characteristics of the respective product, are reported
on a scale of 0-12. Acceptability percent is the total product rating divided by the highest
possible score (12). Favorite and least favorite product frequency percent refer to the frequency
of product selection for each response.
Table 2
Composite Variable Ratings
BP100 HEBI bar SCP HEBI paste eeZee RUSF
Color 1.79 1.90 1.74 1.93 1.89
Smell 1.81 1.82 1.60 1.88 1.84
Taste 1.78 1.90 1.35 1.96 1.89
Appearance 1.88 1.92 1.66 1.87 1.82
Texture 1.70 1.78 1.65 1.86 1.79
Overall 1.80 1.93 1.53 1.96 1.94
Total product rating 10.75 11.26 9.52 11.45 11.17
Acceptability percent 89.60% 93.82% 79.34% 95.43% 93.07%
Favorite product frequency percent 10.50% 21.10% 4.40% 29.80% 34.20%
Least favorite product frequency
percent
20.20% 6.10% 65.80% 4.40% 3.50%
In the composite analysis, HEBI paste received the highest total product rating, closely
followed by HEBI bar and eeZee RUSF. BP100 was next, with SCP receiving the lowest total
product rating. EeZee RUSF was the most commonly selected favorite product, followed by
HEBI paste. The majority of respondents indicated that SCP was their least favorite product.
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Of the characteristics assessed for HEBI bar, texture received the lowest rating and smell
the next-to-lowest rating. HEBI paste’s texture, appearance, and smell, whose scores were
closely grouped, were rated lower than the product’s other characteristics including overall
product rating.
Caretakers’ product ratings are reported in Table 3. These can be compared and
contrasted to children’s variable ratings in Table 4.
Table 3
Caretakers’ Variable Ratings
BP100 HEBI bar SCP HEBI paste eeZee RUSF
Color 1.71 1.88 1.66 1.94 1.85
Smell 1.72 1.75 1.52 1.86 1.77
Taste 1.75 1.85 1.23 1.98 1.91
Appearance 1.86 1.89 1.68 1.85 1.83
Texture 1.69 1.75 1.66 1.89 1.78
Overall 1.75 1.88 1.51 2.00 1.923
Total product rating 10.48 11.00 9.26 11.52 11.06
Acceptability percent 87.33% 91.67% 77.18% 96.03% 92.18%
Favorite product percent 13.80% 12.30% 3.10% 36.90% 33.80%
Least favorite product percent 18.50% 4.60% 73.80% 0.00% 3.10%
Caretakers gave HEBI paste the highest total product rating, followed by eeZee RUSF
and HEBI bar. BP100 received a score in the mid-range, while SCP had the lowest rating.
HEBI paste was the most common choice for favorite product, while the greatest number of
caretakers selected SCP as their least favorite product.
In regards to HEBI bar, scores for smell and texture were the lowest. HEBI paste’s
appearance, smell, and texture received relatively low ratings.
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Table 4
Children’s Variable Ratings
BP100 HEBI bar SCP HEBI paste eeZee RUSF
Color 1.90 1.94 1.84 1.92 1.96
Smell 1.92 1.92 1.71 1.90 1.94
Taste 1.82 1.98 1.51 1.92 1.88
Appearance 1.90 1.96 1.63 1.90 1.82
Texture 1.71 1.82 1.63 1.82 1.80
Overall 1.86 2.00 1.55 1.92 1.96
Total product rating 11.10 11.61 9.87 11.37 11.35
Acceptability percent 92.52% 96.77% 82.26% 94.73% 94.55%
Favorite product percent 6.10% 32.70% 6.10% 20.40% 34.70%
Least favorite product percent 22.40% 8.20% 55.10% 10.20% 4.10%
Children rated HEBI bar the highest, followed by HEBI paste and eeZee RUSF, then
BP100 and SCP. EeZee RUSF was the most common selection for favorite product, while the
majority of child participants indicated that SCP was their least favorite product.
Among HEBI bar characteristic ratings, texture scored the lowest. For HEBI paste,
texture was also rated the lowest.
DISCUSSION
HEBI bar and HEBI paste consistently received high product ratings, putting them within
5 percentage points of the products rated most acceptable for each of the analyses. Though eeZee
RUSF was more frequently selected as the favorite product, HEBI products were more accepted
by participants overall, as evidenced through higher product ratings than eeZee in five cases out
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of six (the exception was caretakers’ rating of HEBI bar, whose total product rating was .51%
lower than that of eeZee RUSF).
Limitations
Sample selection was limited to individuals who were enrolled with their respective
village health educators, and who were available and willing to participate in the study on the
days scheduled. The sample was also restricted to caretaker-child pairs wherein the child was
between four and nine years of age. The specificity of the sample limits the generalizability of
study results to a broader population.
Verbal administration of surveys may have contributed to errors in data collection and
recording. However, interview methods were also used in the studies by Dibari (2013b) and
Cohuet (2012), which formed the basis of this research.
Caretakers provided more critical feedback than children, as reflected in their
acceptability scores, which were generally lower than children’s. Additionally, in several cases
children refused to taste certain products or did not provide answers to all survey questions.
Insufficiently complete surveys were discarded, which resulted in a greater number of
caretakers’ surveys in the analysis.
Conclusions
The findings of this study show that HEBI bar and HEBI paste are acceptable to study
participants in Prey Veng. Diversity of survey locations and respondent demographics suggest
that the results may be generalized to the population of Prey Veng.
If the IRD is to modify HEBI products, it would be recommendable to adjust HEBI bar’s
texture and smell, as well as HEBI paste’s texture, smell, and appearance. These changes are not
19. - 17 -
expedient, but may improve the product’s acceptability in Cambodia. If the products are altered,
they must be re-tested for acceptability.
Before results can be generalized to all of Cambodia, it would be advisable to test product
acceptability in other regions of the country.
Given product acceptability in Prey Veng, it is recommended that HEBI products be
tested for effectiveness in that region.
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22. APPENDIX I: SURVEY INSTRUMENT (Khmer)
This survey was used to collect participants’ personal and health information as well as their
product ratings and reactions. It is included here in the original Khmer version.
26. 24
APPENDIX II: SURVEY INSTRUMENT (English)
Though administered in Khmer, the survey instrument has been translated to English for improved understanding
of English-speakers.
27. - 25 -
RUTF Questionnaire
1. Date: ___ / ___ / 2013 2. Interviewer name: __________________________ 3. Participant number: _____M / C
4. Caretaker relationship to child: mother / father / blood-related aunt / grandmother / other: ____________________
5. Caretaker name: ________________________ 6. Caretaker age: ____ 7. Caretaker gender: M / F
8. Child name: _________________________ 9. Child age: ____ 10. Child gender: M / F
11. Child weight: ____kg 12. Child height: ____m 13. Child MUAC: _____mm
Questions
Please tell me about the food you have just eaten:
BP100 HEBI bar SCP HEBI paste eeZee RUSF
14. How was
the color?
15. How was
the smell?
16. How was
the taste?
17. How did it
look?
18. How was
the texture?
19. How was
the food
overall?
28. - 26 -
20. Any other comments: ____________________________________________________________________________________
21. Please select which food you like best: BP100 / HEBI bar / SCP / HEBI paste / eeZee RUSF
22. Please select which food you like least: BP100 / HEBI bar / SCP / HEBI paste / eeZee RUSF
