RUTF PRODUCTS IN RURAL CAMBODIA

The acceptability study of a novel ready-to-use

therapeutic food

Kira Anderson, MPH CandidateSummer 2013

A study report

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

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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)

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

Research Design

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.

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Table 1

Product Rating Matrix

BP100 HEBI bar SCP HEBI paste eeZee RUSF

Bad Okay Good Bad Okay Good Bad Okay Good Bad Okay Good Bad Okay Good

ColorFrequency 3 18 93 0 11 103 3 24 87 0 8 106 2 8 104

Percent 2.6% 15.8% 81.6% 0% 9.6% 90.4% 2.6% 21.2% 76.3% 0% 7.0% 93.0% 1.8% 7.0% 91.2%

SmellFrequency 3 16 94 2 16 96 7 31 75 0 14 100 2 14 97

Percent 2.6% 14.0% 82.5% 1.8% 14.0% 84.2% 6.1% 27.2% 65.8% 0% 12.3% 87.7% 1.8% 12.3% 85.1%

Taste Frequency 5 15 94 1 9 104 23 28 63 2 1 111 4 4 106

Percent 4.4% 13.2% 82.5% 0.9% 7.9% 91.2% 20.2% 24.6% 55.3% 1.8% 0.9% 97.4% 3.5% 3.5% 93.0%

Appearance Frequency 1 12 101 0 9 105 9 21 84 3 9 102 2 16 96

Percent 0.9% 10.5% 88.6% 0% 7.9% 92.1% 7.9% 18.4% 73.7% 2.6% 7.9% 89.5% 1.8% 14.0% 84.2%

Texture Frequency 4 26 84 3 19 92 9 22 83 2 12 100 4 16 94

Percent 3.5% 22.8% 73.7% 2.6% 16.7% 80.7% 7.9% 19.3% 72.8% 1.8% 10.5% 87.7% 3.5% 14.0% 82.5%

Overall Frequency 5 13 96 1 6 107 16 22 76 2 0 112 3 1 110

Percent 4.4% 11.4% 84.2% 0.9% 5.3% 93.9% 14.0% 19.3% 66.7% 1.8% 0% 98.2% 2.6% 0.9% 96.5%

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

BP100HEBI 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.

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.

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In regards to HEBI bar, scores for smell and texture were the lowest. HEBI paste’s

appearance, smell, and texture received relatively low ratings.

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

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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

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.

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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

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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Wieringa, F (2013). Acceptability trial on locally produced Ready-to-Use Therapeutic Food (RUTF). Research proposal, IRD. Accessed via verbal presentation and hard copy.

Yang, Y, Van den Broeck, J, & Wien, L (2013). Ready-to-use food-allocation policy to reduce the effects of childhood undernutrition in developing countries. Proceedings of the National Academy of Sciences of the United States of America: Early Edition, 2013. Retrieved from http://www.pnas.org/content/early/2013/02/27/1216075110.full.pdf+html

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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.

sMNYrxøI²eRkayeBlPøk;Gahar RUTF TaMg 5 RbePTrYc³1-éfçTI ____/____/ 2013 2-eQaµHGñksMPasn_³ ________________________ 3-elxerogGñkcUlrYm:

__________________ mþayb¤kUn 4- PUmi >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

5- mNÐlsuxPaB>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> 6- RsukRbtibtþi>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

7-eQaµHGñkEfTaMkumar³ ………………………8-GayuGñkEfTaMkumar:………… 9-ePT³ Rbus ¼RsI 10- etIRtUvCaGVICamYynwgkumar³ mþay¼«Buk¼CIdUn¼bg¼sac;BaaJti¼epSg² 11-eQaµHkumar…………………………12- Gayukumar ……… 13- ePT³ Rbus ¼RsI

14- Tm¶n;kUn: ……………..kg 15- km<s;:…………….mm 16- MUAC:

_____mmsMNYr³ sUmGñkCYyR)ab;BIkaryl;eXIjGMBIGaharEdlGñkeTIbnig)anPøk;ehIyG

M)aj;mij22

BP100 HEBI bar SCP HEBI paste eeZee RUSF

17-etIBN’y:agNaEdr?

18-etIkøiny:agNaEdr?19-etIrsCatiy:agNaEdr?20-etIrUbragy:agNaEdr?21-etIBi)akelbEdrb¤eT?22-etICaTUeTAGñk

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eBjcitþGaharenHeT?

23- mtieyabl;epSg²³ _______________________________________________________________________________________________

24- sUmGñkeRCIserIsykGaharNamYyEdlcUlcitþCageK³ BP100 / HEBI bar / SCP / HEBI paste / eeZee RUSF

25- sUmGñkeRCIserIsykGaharNamYyEdlmincUlcitþ³ BP100 / HEBI bar / SCP / HEBI paste / eeZee RUSF

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APPENDIX II: SURVEY INSTRUMENT (English)

Though administered in Khmer, the survey instrument has been translated to English for improved understanding of English-speakers.

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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

QuestionsPlease 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?

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18. How was the texture?

19. How was the food overall?

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

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