Evaluation of the acceptability of improved supplementary foods for the treatment of moderate acute malnutrition in Burkina Faso using a mixed method approach

E alua ion o he accep abili y o imp o ed supplemen a y oods o he ea men o mode a e acu e malnu i ion in Bu kina Faso using a mixed me hod app oach Ann-Sophie Iuel-B ockdo a , b , * , Tania Aase D aebel c , Ch is ian Ri z b , Ch is ian Fabiansen b , Be na de e Cichon b , Vibeke B ix Ch is ensen b , d , Cha les Yameogo b , e , RouafiOummani , And  e B iend b , Kim F. Michaelsen b , Pe Asho n g , Suzanne Fil eau h , Hen ik F iis b a M edecins Sans F on i e es eDenma k, D onningensgade 68, 3, 1420, Copenhagen, Denma k b Depa men o Nu i ion, Exe cise and Spo s, Uni e si y o Copenhagen, Roligheds ej 30, DK-1958, F ede iksbe g C, Denma k c Depa men o In e na ional Heal h, Facul y o Heal h and Medical Sciences, Uni e si y o Copenhagen, Blegdams ej 3, 2200, Copenhagen, Denma k d Depa men o Paedia ics, Righospi ale , Blegdams ej 9, 2100, Copenhagen, Denma k e Cen e de Reche che en Sciences Biologiques, Alimen ai es e Nu i ionalles, Uni e si  e de Ouagadougou, 03 BP 7131, Ouagadougou, Bu kina Faso ALIMA eThe Alliance o In e na ional Medical Ac ion, Rou e de l’A e opo , Rue NG 96 BP: 12000 R esidence, Daka , Senegal g Uni e si y o Tampe e School o Medicine, L€ a€ ak€ a inka u 1, 33014, Uni e si y o Tampe e, Finland h London School o Hygiene and T opical Medicine, Facul y o Epidemiology and Popula ion Heal h, Keppel S ee , London, WC1E 7HT, UK a icle in o A icle his o y: Recei ed 13 Sep embe 2015 Recei ed in e ised o m 28 Decembe 2015 Accep ed 29 Decembe 2015 A ailable online 2 Janua y 2016 Keywo ds: Accep abili y Supplemen a y ood Lipid-based nu ien supplemen Co n soy blend Mode a e acu e malnu i ion abs ac The objec i e o his s udy was o e alua e, wi hin he con ex o a andomized con olled ial o p oduc e ec i eness, he accep abili y o new o mula ions o six co n-soy blended flou s (CSB) and six lipid- based nu ien supplemen s (LNS) wi h di e en quan i ies o milk and quali ies o soy o he ea - men o child en wi h mode a e acu e malnu i ion (MAM). Ou s udy included 1546 child en aged 6e23 mon hs and in ol ed ques ionnai es a e one mon h o supplemen a ion home isi s and in e iews wi h a sub-sample o 20 ial pa icipan s and hei ca e- ake s, and nine ocus g oup discussion. All 12 p oduc s we e well accep ed in e ms o o ganolep ic quali ies and ecei ed good a ings. Howe e , LNS we e mo e app ecia ed by ca e ake s and child en. Addi ionally, an e ec o soy isola e was de ec ed on child app ecia ion whe e p oduc s wi h high milk con en also ecei ed be e a ings. CSB we e no consumed as eadily; 33.9% (n ¼257) o child en ecei ing CSB we e epo ed o ha e le o e s compa ed o 17.3% (n ¼134) o child en ecei ing LNS (p¼<0.001). Bo h CSB and LNS we e e e ed o as oods wi h medicinal p ope ies and pe cei ed as beneficial o child heal h. They we e bo h epo ed o ha e high p io i y in he daily eeding o he child. In conclusion, he e we e minimal di e ences in accep abili y o he a ious CSB and LNS o mula ions, al hough CSB we e less eadily consumed and equi ed smalle meal olumes. Since all p oduc s we e well-accep ed, decisions ega ding whe he he mo e expensi e p oduc s should be used o he ea - men o MAM will need o be based on hei e ec on child nu i ion, g ow h and heal h. Fu u e sup- plemen a y eeding p og ams in simila con ex s could u he mo e conside in oducing supplemen a y oods as a medical ea men , as his may inc ease adhe ence and dec ease sha ing. ©2016 The Au ho s. Published by Else ie L d. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/). Abb e ia ions: MAM, mode a e acu e malnu i ion; CSB, co n-soy blends; LNS, lipid-based nu ien supplemen s; WHO, Wo ld Heal h O ganiza ion; DS, dehulled soy; SI, soy isola e; DSM, d y-skimmed milk; MUAC, mid-uppe a m ci cum e ence. *Co esponding au ho . Depa men o Nu i ion, Exe cise and Spo s, Uni e si y o Copenhagen, Roligheds ej 30, 1958, F ede iksbe g C, Denma k. E-mail add esses: [email p o ec ed],[email p o ec ed] (A.-S. Iuel-B ockdo ), [email p o ec ed] (T.A. D aebel), [email p o ec ed] (C. Ri z), [email p o ec ed] (C. Fabiansen), [email p o ec ed] (B. Cichon), [email p o ec ed] (V. B ix Ch is ensen), yamwa[email p o ec ed] (C. Yameogo), [email p o ec ed] (R. Oummani), and e.b iend@gmail. com (A. B iend), [email p o ec ed] (K.F. Michaelsen), pe .asho n@u a.fi(P. Asho n), [email p o ec ed] (S. Fil eau), [email p o ec ed] (H. F iis). Con en s lis s a ailable a ScienceDi ec Appe i e jou nal homepage: www.else ie .com/loca e/appe h p://dx.doi.o g/10.1016/j.appe .2015.12.030 0195-6663/©2016 The Au ho s. Published by Else ie L d. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/). Appe i e 99 (2016) 34e45 1. In oduc ion Mode a e acu e malnu i ion (MAM) defined as a weigh - o heigh z-sco e (WHZ) be ween 2 and 3, a ec s a ound 33 million child en and is a majo global heal h p oblem, causing inc eased mo bidi y and mo ali y and delayed cogni i e de el- opmen (M.M Black e al. 2008; R.E Black e al. 2013; Len e s, Wazny, Webb, Ahmed, &Bhu a, 2013). Despi e he de elopmen o lipid-based nu ien supplemen s (LNS) and enhanced e sions o co n-soy blends (CSB) in ecen yea s, he e is cu en ly no s anda dized p ac ice o he managemen o MAM. A la ge e i- dence base o ensu e in o med policies on e ficacious ea men o MAM is he e o e needed (Kennedy, B anca, Webb, Bhu a, & Rebecca, 2015; Wo ld Heal h O ganiza ion, 2012). The de elopmen o new supplemen a y oods o he ea men o MAM is challenged by many unce ain ies which may a ec he accep abili y o he oods, due o di e ence in o mula, o ganolep ic quali ies and fla ulence ac o (B iend, AkomoBahwe eDe PeeDiba iGolden, Mana y, &Ryan, 2015). Poo accep abili y may lead o subop imal use, hus ende ing nu i ional in e en ions less beneficial in e ms o g ow h and eple ion o nu i ional de- ficiencies (Flax e al. 2010; San os e al. 2005). An unde s anding o ac o s a ec ing accep abili y is he e o e essen ial o an e ec i e p o ision o supplemen a ion p og ams. Soy isola es and dai y p oduc s ep esen fi s choice in e ms o quali y and low le els o an i-nu ien s in supplemen a y oods, bu a e expensi e ing edien s. The o mula ion o al e na i e oods wi h mo e c ude, less expensi e soy p oduc s o wi h lowe quan i ies o milk could imp o e co e age o ea men o MAM bu would be wo h implemen ing only i bo h e ficacy o child heal h and accep abili y o he p oduc s was no comp omised by using cheape e sions. Accep abili y o soy s milk-based oods o he managemen o MAM ha e so a also only been compa ed in a ew s udies, and only in LNS, whe e bo h we e epo ed o be well- accep ed (Kuusipalo, Male a, B iend, Mana y, &Asho n, 2006; Mangani e al. 2013; Ma ilsky, Male a, Cas leman, &Mana y, 2009). The accep abili y o CSB s LNS has also p e iously been in es iga ed, wi h esul s indica ing simila accep abili y (Flax e al. 2009; Ma ilsky e al. 2009). Howe e , CSB we e mo e likely o be sha ed (Wang e al. 2013) and LNS we e less likely o be le -o e (Flax e al. 2010; Iuel-B ockdo e al. 2015). To ou knowledge, no s udies ha e assessed and compa ed he accep abili y o CSB s LNS, bo h wi h di e en quan i ies o milk and di e en quali ies o soy. The objec i e o ou s udy was o e alua e he accep abili y o new o mula ions o CSB and LNS wi h di e en quan i ies o milk and wi h soy isola es o soy flou de eloped o he managemen o MAM. Accep abili y was assessed based on gene al app ecia ion and o ganolep ic quali ies, he ecommended quan i y consumed, pe cep ions abou he supplemen s, hei pe cei ed ease o use and sha ing p ac ices, which a e indica o s o accep abili y p e iously used (Adu-A a wuah e al. 2008; Bahwe e, Sadle , and Collins 2009; Cohue e al. 2012; Rowe, B odega d, Pike, S eele, &Dunn, 2008). A mixed app oach o quan i a i e and quali a i e me hods was applied o ob ain de ailed and nuanced in o ma ion conce ning ac o s ha could a ec accep abili y. 2. Me hods 2.1. S udy se ing The s udy ook place in he P o ince du Passo  e in he No he n egion o Bu kina Faso be ween Sep embe 2013 and Feb ua y 2015. The p e alence o se e e acu e malnu i ion (SAM) defined as a weigh - o -heigh o less han 3 z-sco es o a mid-uppe a m ci cum e ence (MUAC) o less han 115 mm and o MAM in he a ea we e 1.4% and 9%, espec i ely (Minis e e de la San  e, Bu kina Faso, Di ec ion de la Nu i ion 2013). A 3e5 mon hs long hunge -gap ea pe iod o seasonal sca ci y be ween ha es s eusually s a s om June (Famine Ea ly Wa ning Sys ems Ne wo k, 2014) and coincides wi h he ainy season. The s udy was conduc ed a fi e si es, all es ablished as pa o go e nmen al heal h cen es (Gomponsom, La oden, Baga  e, Bokin and Samba), whe e esea ch ac i i ies we e managed by locally ec ui ed s a om he non-go e nmen al o ganiza ion Alliance o In e na ional Medical Ac ion (ALIMA). 2.2. In e en ion The supplemen a y oods included six CSB and six LNS wi h ei he dehulled soy (DS) o soy isola e (SI) and wi h 0%, 20% o 50% o o al p o ein as d y-skimmed milk (DSM). All supplemen s we e manu ac u ed by GC Riebe Compac A/S (Be gen, No way) and had simila mic onu ien con en p o ided by a p e-mix o i amins and mine als designed acco ding o a WHO Technical No e on supplemen a y oods o he managemen o MAM (Wo ld Heal h O ganiza ion, 2012)(Table 1). A daily a ion o LNS (92 g, 60 ml olume) and CSB (120 g, 600 ml olume) p o ided 500 kcal pe child. LNS we e packed in 92 g oil sache s con aining a daily a ion and did no equi e any p epa a ion. Ca e ake s we e ad ised o se e one sache o LNS in one o mo e meals h oughou he day. I he child was no able o comple e one sache in one day, disca ding he sache was ins uc ed and s a ing wi h ano he one he nex day. CSB supplemen s we e packed in oil bags o 1.7 kg, co e- sponding o 14 days o daily a ions. The CSB flou s we e ecom- mended o be cooked wi h wa e and se ed as po idge. Indi idual dose cups (pe meal) we e p o ided and ca e ake s we e ins uc ed how o p epa e he po idge wi h a CSB-wa e olume a io o 1:4. They we e ad ised o se e he po idge in 3 meals pe day, gi ing 40 g o CSB (167 kcal) pe meal. This co esponded o a ound 200 ml pe meal, in o de no o exceed he gas ic capaci y o he child (Pan Ame ican Heal h O ganiza ion, Wo ld Heal h O ganiza ion 2003). Ca e ake s we e ad ised o disca d le o e s. Ca e ake s we e in o med ha hei child en we e malnou - ished. All supplemen s we e in oduced as a medical ea men o ea malnu i ion and o be exclusi ely consumed by he child included in he s udy in addi ion o amily oods (Box 1). The s udy was conduc ed as pa o a andomized con olled ial in es iga ing he e ec i eness o he 12 new o mula ions o CSB and LNS o he ea men o MAM. The ial is egis e ed a www.con olled- ials.com (ISRCTN42569496). E ec i eness e- sul s o he ial will be epo ed sepa a ely. The s udy included ques ionnai es o all ial pa icipan s, as well as indi idual in- e iews, ocus g oup discussions (FGD) and home isi s wi h s uc u ed obse a ions on a subsample o ial pa icipan s. 2.3. Quan i a i e assessmen : ques ionnai e-based e alua ion a e one mon h o supplemen a ion 2.3.1. Pa icipan s Child en we e sc eened by MUAC in illages by communi y heal h wo ke s o by designa ed sc eening eams using bo h MUAC and WHZ. Addi ionally, ca e ake s could b ing child en o he s udy si e, o be e e ed om a heal h cen e. Final assessmen o s udy eligibili y was pe o med a si es. Child en aged 6e23 mon hs wi h MAM, defined as MUAC 115 mm and <125 mm and/o WHZ 3 and <2 based on WHO g ow h e e ence (WHO jWHO Child G ow h S anda ds, A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e45 35 2014) and esiden in he ca chmen a ea we e andomized o pa icipa e in he s udy. I mo e han one child om he same amily (same mo he and same a he ) we e eligible, only he fi s child assessed was andomized. Howe e , o p e en mixing o sha ing o he supplemen s, wins wi hou malnu i ion and sib- lings aged 6e23 mon hs wi h MAM ecei ed he same supplemen . The ca egi e s ga e e bal and w i en consen by humb p in p io o en olmen . 2.3.2. Design Child en we e andomised o one o he 12 di e en supple- men s acco ding o a blocked andomisa ion lis using h p://www. andomiza ion.com,wi h a ying blocks o 12 o 24 and s a ified by si e. A e one mon h o supplemen a ion, ca e ake s ga e e bal answe s o a s uc u ed ques ionnai e conduc ed by a esea ch assis an dedica ed specifically o his ask. The ques ions we e asked and answe ed in he local language and included ques ions Table 1 Food composi ion able o he 12 expe imen al supplemen a y oods. Nu ien Uni Recommended composi ion a Co n soy blend (CSB) pe 120 g b Lipid-based nu ien supplemen (LNS) pe 92 g 1234 5 6 789101112 Ene gy Kcal 500 kcal 500 kcal 500 kcal Fa g 12.5e32.5 11.4 11.7 11.4 11.4 11.4 11.4 31.6 31.5 32.1 31.4 31.5 31.4 P o ein g 10e21.5 16.8 16.5 16.5 15.9 16.2 16.5 13.5 13.5 13.1 12.5 12.8 13.1 Soy quali y c Flou Flou Flou Isola e Isola e Isola e Flou Flou Flou Isola e Isola e Isola e DSM d % 0 20 50 0 20 50 0 20 50 0 20 50 Calcium mg 500e700 600 600 I on e mg 9e15 12 12 Magnesium mg 140e210 175 175 Phospho us mg 425e700 563 563 Po assium mg 750e1100 925 925 Sodium mg max 250 <250 <250 Zinc mg 10e17.5 14 14 Coppe mg 0.5e1.8 1.15 1.15 Manganese mg 0.5e1.0 0.75 0.75 Selenium m g 17.5e45 31.5 31.5 Iodine m g75e175 125 125 Vi amin C mg >75 188 94 Thiamin B1 mg >0.5 1.0 0.65 Ribofla in B2 mg >2.0 3.0 2.5 Niacin mg >12.5 20.2 15.5 Pan o henic acid mg >2.5 4.5 3.2 Vi amin B6 mg >11.8 1.25 Fola e g m g>200 510 425 Bio in m g>10 13.8 12.5 Vi amin B 12 m g>2.5 4.1 3.15 Re inol m g 1000e1500 1375 1250 Vi amin E mg >15 22.8 19 Vi amin D m g10e30 22.0 20 Vi amin K m g>25 34.7 31.5 a WHO jTechnical No e: supplemen a y oods o he managemen o mode a e acu e malnu i ion in in an s and child en 6e59 mon hs o age, 2012. b The con en o some o he wa e soluble i amins ha e been inc eased o compensa e o deg ada ion du ing cooking o CSB. c Flou ¼Dehulled soy flou ; Isola e ¼Soy p o ein isola e. d D y Skimmed Milk, p esen ed as pe cen age o o al p o ein. e Range o ecommended alues based on 10e5% bioa ailabili y (WHO, 2012). Excluding Phospho us om phy a e as i is no bioa ailable (WHO, 2012). g Die a y ola e equi alen . A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e4536 e alua ing he app ecia ion, as e, colou , odou and ex u e o he supplemen s acco ding o he child's eac ion as pe cei ed by he ca e ake and ca e ake 's own pe cep ion, based on a 5-poin he- donic scale, whe e 1 ¼ e y good, 2 ¼good, 3 ¼neu al, 4 ¼bad and 5¼ e y bad. The scale was illus a ed in a se ies o human ace symbols wi h a ying deg ees o smile o discon en , which is a me hod p e iously used o measu e ood accep abili y in illi e a e popula ions (Cohue e al. 2012; Hess e al. 2011). Addi ionally, ques ions ela ed o he managemen o he supplemen a y oods and pe cep ions o hei u ilisa ion and e ec s we e included. The ques ionnai e was de eloped oge he wi h a local esea ch assis- an and pilo ed p io o he s udy (Iuel-B ockdo e al. 2015). Following he pilo s udy, ew adjus men s in e ms o modifica ion and eph asing o ce ain ques ions we e made. 2.4. Quali a i e assessmen : home isi s and ocus g oup discussions 2.4.1. Pa icipan s Pu posi e sampling was used o his pa o he s udy by including a subsample o pa icipan s om he main ial, ec ui ed a h ee o he fi e esea ch si es (Gonponsom, La oden and Bokin). The s udy was conduc ed bo h du ing he d y and ainy season as seasonali y was conside ed o influence eeding p ac ices and ood a ailabili y which could a ec accep abili y. S udy pa icipan s om each o he main supplemen al ood ca ego ies (CSB and LNS) we e selec ed, bu as he ial was blinded, o he aspec s o he ood composi ion (quali y o soy and quan i y o milk) we e no conside ed in he selec ion. 2.4.2. Design A subsample o 20 ca e ake s and hei child en we e obse ed du ing home isi s o h ee consecu i e days du ing day ime ( om 7-8 am o 5e6 pm) by a ained emale local esea ch as- sis an . The obse a ions ook place a e a minimum o one mon h o supplemen a ion. The assis an ollowed a s uc u ed obse a ion schedule wi h he aim o assessing eeding beha iou s in ela ion o supplemen a y eeding and also ook no es h oughou he day. Addi ionally, he numbe o daily a ions o supplemen le in he household was assessed a he fi s day and compa ed o numbe o days un il nex supplemen a ion isi . Finally, ca e ake s we e asked o e alua e he heal h s a us o hei child e e y day du ing he h ee days o obse a ion on a scale om one o en, whe e one was pe ec ly heal hy and en was as sick as could be imagined. Indi idual in e iews we e ca ied ou wi h he 20 ca e ake s a he second day o he home isi s. Addi ionally, nine FGDs we e ca ied ou a he esea ch si es wi h ca e ake s o o he pa ici- pan s om he main ial, in g oups o fi e o se en pa icipan s pe g oup. Bo h me hodologies we e used o explo e pe cep ions abou he supplemen s. The numbe o in e iews/FGDs was based on he p inciple o da a sa u a ion, including new pa icipan s as long as new hemes eme ged, so ha eme ging in o ma ion would be comp ehensi e, sa u a ed and accoun o de ian cases, wi h he aim o achie ing analy ical gene aliza ion. The in e iews and FGDs we e ca ied ou in he local language Moo  e by wo esea ch as- sis an s ained o he pu pose by he fi s au ho . The in e iews and FGDs las ed be ween 20 and 45 min and we e ca ied ou ollowing a semi-s uc u ed in e iew guide using mainly open- ended ques ions. The in e iew guide was ca e ully discussed and de eloped wi h he esea ch assis an s p io o he s udy, o ensu e seman ic cohe ence and ele ance o he con ex . All in e iews and FGDs we e eco ded, ansc ibed and ansla ed om Moo  e o F ench by he esea ch assis an s and om F ench o English by he fi s au ho . The analysis o he da a was done using he English ansla ion. 3. Da a analysis Quan i a i e da a including da a om he s uc u ed ques ion- nai es and he home isi s we e doubly en e ed in o Epida a 3.1 So wa e (Epida a Associa ion, Odense, Denma k) and analysed using S a a 12 (S a aCo p, College S a ion TX, USA). Fo con inuous ou comes (app ecia ion, o ganolep ic quali ies o he supplemen a y oods and equency o eeding), linea mixed models we e fi ed; supplemen s as well as adjus men o age, sex, and season we e fixed e ec s and si es we e included as andom Box 1 Educa ional messages abou he use o he p oduc s. Gene al The supplemen is a ea men o ea malnu i ion The supplemen should no be sha ed wi h o he s Fo b eas ed child en, b eas eeding should be con inued on demand. Child en <12 mon hs should be b eas ed p io o supplemen a ion. The supplemen should no eplace local oods bu be gi en in addi ion o hem. CSB LNS The po idge should be gi en 3 imes a day Use clean wa e o he p epa a ion o he po idge Take ou cups o wa e o one cup o lou . Wa e can be educed o inc eased depending on desi ed iscosi y o po idge. Once wa e is boiling, add he lou and boil o a minimum o 5 min and a maximum o 10 min. Po idge should cool o o a ew minu es be o e gi ing i o he child. Use a sepa a e pla e o eed he child o make su e he o she ea s all he ood gi en, and ha i is no sha ed wi h o he s Po idge should be ea en immedia ely a e being p epa ed. Unea en po idge mus no be sa ed o la e . Po idge ha is kep o oo long can make he child sick The po idge may no be sha ed wi h o he child en o adul s One sache pe child pe day e his can be di ided in se e al meals Be o e opening he sache , squeeze he con en a ound and ensu e ha i is mixed well Be o e opening he sache , wash i wi h wa e and soap The supplemen does no equi e any p epa a ion, bu can be gi en s aigh om he sache o on a inge o a spoon I he child canno inish he supplemen in one ake, close he sache ca e ully and keep i s o ed in a clean, d y and cool place. Then y again la e . I he supplemen is no ea en by he end o he day, do no sa e i o he nex day O e plen y o clean wa e o d ink when he child is ea ing he supplemen , he child will need o d ink mo e wa e han usual The supplemen mus no be sha ed wi h o he child en o adul s A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e45 37 e ec s o accoun o clus e ing e ec s. Model checking was based on isual inspec ion o esidual and no mal p obabili y plo s. Repo ed le o e s (yes/no) we e ea ed as bina y ou come and analysed using logis ic mixed-e ec s eg ession including adjus - men o age and sex and andom e ec s o si es. Addi ionally, he in e ac ion be ween p oduc g oups (CSB and LNS) and age g oups (2 in e als: 6e11 mon hs and 12e23 mon hs) was in es iga ed in a sepa a e analysis, also using logis ic mixed-e ec s eg ession. Specifically o he con inuous ou comes pe aining o app ecia ion and o ganolep ic quali ies as well as o he bina y ou come (le - o e s), di e ences be ween he 12 supplemen s we e e alua ed in e ms o he h ee-way in e ac ion be ween CSB/LNS, soy quali y, and quan i y o milk. Likelihood a io es s we e used o his e alua ion. I significan , pai wise compa isons be ween supple- men s we e ca ied ou . O he wise each o he h ee ac o s (main e ec s) was e alua ed sepa a ely by means o pai wise compa i- sons o ac o le els. Fo he o de ed mul inomial ou comes ela ed o he pe cep ion and managemen o he supplemen s, o de ed logis ic eg ession models we e fi ed. These models also included adjus men o age, season, and sex. To accoun o clus e ing e ec s due o he si es, obus s anda d e o s we e used. Fo hese ou comes, only he main e ec o CSB/LNS was conside ed, and epo ed as pe cen - ages. T- es s we e used o compa e LNS and CSB. The analysis o he quali a i e da a was done manually by he fi s au ho , using p inciples o Quali a i e Con en Analysis as desc ibed by G aneheim and Lundman (2004). Fi s , each in e iew and FGD was kep in ac and ead h ough se e al imes in bo h F ench and English o ob ain a gene al sense o he con en , sea ching o common hemes and iden i ying mani es and la en con en pe aining o he aim o his s udy. F om he English ex , condensed meaning uni s o po ions o he ex ha we e con- nec ed o a cen al meaning we e o med and coded o ha spe- cific meaning and classified in o ca ego ies (mo e han one pe uni was pe mi ed) om whe e hemes eme ged. Finally, findings om each o he in e iews/FGDs we e compa ed wi h he aim o explo ing simila i ies, di e ences and pa e ns in he accep abili y o CSB and LNS, wi h a ocus on he subjec and he con ex . O he aspec s o he composi ion o he p oduc s, such as he quali y o soy and quan i y o milk, o which he pa icipan s we e blinded, we e no conside ed in he analysis o he findings. 4. E hical app o al As pa o he main ial, his s udy was app o ed by he E hics Commi ee o Heal h Resea ch in Bu kina Faso (2012-8-059) and consul a i e app o al was ob ained om he Danish Na ional Commi ee on Biomedical Resea ch E hics (1208204). 5. Resul s 5.1. Cha ac e is ics o pa icipan s om he ques ionnai es Du ing he cou se o nine mon hs, 1.613 child en we e included in he main s udy. O hese, 1.546 (95.8%) child en, who had comple ed one mon h o supplemen a ion, we e included in his analysis (Fig.1). The mean age (SD) was 13.3 (4.8) mon hs and 94.6% (n ¼1460) o he child en we e b eas ed a he ime o inclusion. The e hnici y o ca e ake s was Mossi o 94.1% (n ¼1512). The majo i y, 59.0% (n ¼949), we e Muslim, 23.7% (n ¼381) we e Ca holic, 6.2% (n ¼99) we e P o es an and 11.1% (n ¼178) had adi ional belie s. Randomiza ion gene ally esul ed in baseline equi alence, excep ha p opo ion o males anged om 41.5 o 51.9% (Table 2). 5.2. Cha ac e is ics o pa icipan s om he home isi s/in e iews and FGDs Fo he obse a ional isi s, he 20 child en and hei ca e ake s om he main ial ec ui ed had baseline cha ac e is ics simila o he la ge g oup in he ques ionnai e componen o he s udy. Ten o he child en ecei ed CSB and en ecei ed LNS. Eigh een o he child en we e li ing wi h bo h pa en s, while one li ed wi h only he mo he and one li ed wi h he g andmo he . The mean heal h s a us sco e (SD) was 1.9 (1.7) o child en ecei ing CSB and 1.4 (0.5), o child en ecei ing LNS on he heal h s a us sco e om one o en, wi h one being he mos heal hy. The mean du a ion o he home isi s (SD) we e 9.4 h (0.7), and child en had comple ed an a e age (SD) o 6.5 (2.2) weeks o supplemen a ion a he ime o he isi . A o al o 95 meals wi h he supplemen a y oods we e obse ed du ing he home isi s: 48.4% (n ¼46) we e CSB meals and 51.6% (n ¼49) we e LNS meals. Fi y pe cen (n ¼30) o he home isi s we e conduc ed du ing he ainy season. Eigh o he FGDs we e wi h ca e ake s o child en ecei ing only one o he p oduc ypes (CBS o LNS) and one mixed FGD wi h ca e ake s o child en ecei ing ei he CSB o LNS. A o al o 51 emale ca e ake s pa icipa ed in he FGDs and he mean (SD) age was 30 yea s (7.2). 5.3. Ques ionnai e-based e alua ion The mean a ing in e ms o app ecia ion and o ganolep ic p ope ies anged om 1.74 o 2.02 on a scale om one o fi e, wi h one being e y good and fi e being e y bad (Table 3). When e alua ing h ee way in e ac ions be ween CSB/LNS, soy quali y, and quan i y o milk, we ound no in e ac ion, excep in e ms o child app ecia ion, whe e an e ec o soy isola e was de ec ed; CSB wi h soy isola e ecei ed 0.15 (95% CI -0.07; 0.24) poo e (highe ) a ings han CSB wi h dehulled soy (p ¼0.001) and LNS wi h soy isola e ecei ed 0.06 (95%CI -0.15; 0.03) be e (lowe ) a ings han LNS wi h dehulled soy (p ¼0.190). P oduc s wi h high milk con en ecei ed 0.08 (95% CI -0.16;0.01) be e (lowe ) a ings on his pa ame e (p ¼0.025) (Table 3). In e ms o bo h child and ca e ake s app ecia ion, LNS showed lowe (be e ) a ings compa ed o CSB (es . di . 0.16, 95% CI -0.22; 0.10, p <0.001 and es . di . 0.06, 95% CI -0.09; 0.02, p¼0.004, espec i ely) (Table 3). Las ly, al hough di e ences we e small, he e was an associa ion be ween season and a ing wi h lowe (be e ) a ings du ing he ainy season (JuneeOc obe ) han du ing he d y season (No embe eMay) in e ms o child app e- cia ion (0.13 (95% CI -0.20; 0.07), p <0.001), odo (0.07 (95% CI -0.12; 0.01), p ¼0.015), and ex u e (0.04 (95% CI -0.07; 0.003), p¼0.030). The daily ecommended a ion o consume was epo ed o be adequa e by he majo i y o ca e ake s, al hough, he e we e di - e ences be ween CSB and LNS (p ¼0.029) (Table 4). Le o e s a he end o he day we e mo e equen ly epo ed in he CSB g oup compa ed o he LNS g oup (33.9% s 17.3%, p <0.001) and we e less likely du ing he ainy season (OR ¼0.66, p ¼0.05). The e we e no in e ac ion be ween age g oup and CSB/LNS (p ¼0.80). Howe e , younge child en (6e11 mon hs) we e mo e likely o ha e le o e s compa ed o olde child en (12e23 mon hs) (31.4% s 20.1%, p<0.001). Finally, he quan i y o and managemen o le o e s di e ed be ween CSB and LNS as desc ibed in Table 4. The majo i y o ca e ake s said ha hey pe cei ed he supple- men s mainly as medicine o child en (54.8%, n ¼845) o i amins (32.2% n ¼497), ha he supplemen should be dis ibu ed o malnou ished child en (84.6%, n ¼1305) and gi en o ea child en om malnu i ion (87.2%, n ¼1.345) (Table 5). A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e4538 5.4. Findings om he home isi s The e was no di e ence be ween CSB and LNS in e ms o amoun o excess o sho age o daily a ions (p ¼0.99). A mean (95% CI) numbe o 0.5 (0.9; 2.8) o excess a ion was ound, co esponding o 3.6% o he o nigh ly a ion. Le o e s we e egis e ed a e he meal wi h he supplemen- a y oods in 84.8% (n ¼39) o he CSB meals (se ing 40 g, 1/3 o a daily a ion) and in 77.6% (n ¼39) o he LNS meals (se ing 92 g, one daily a ion) (p ¼0.04). Younge child en (6e11 mon hs) we e mo e likely o ha e le o e s (da a no shown), bu he e was no in e ac ion be ween p oduc g oups and age g oups (p ¼0.22). Hal o mo e han hal o he CSB supplemen was le in 66.7% (n ¼26) o he obse ed meals and in 68.4% (n ¼26) o he LNS meals. Le o e s o CSB we e ei he h own ou (41%, n ¼16), consumed by ano he child (30.8%, n ¼12) o sa ed o la e (23.1% n ¼9). Le o e s o LNS we e mainly obse ed o be sa ed o la e (89.5%, n¼34), and epo ed o be consumed in he e ening o h own ou (7.9%, n ¼3). In one LNS meal (2.6%), le o e s we e obse ed o be consumed by ano he child. Sha ing o he supplemen a y oods was obse ed in 37.0% (n ¼17) o he CSB meals and in 36.7% (n ¼18) o he LNS meals, p edominan ly wi h ano he child in he household (CSB: 82.4% (n ¼14), LNS: 94.4%, n ¼17). Ca e ake s we e ecipien s o he emaining sha ed meals. Whe eas sha ing o LNS was mainly done du ing he supplemen a y meal (88.9%, n ¼16), sha ing o CSB was p ima ily done a e wa ds (76.5% n ¼13). 5.5. In e iews and ocus g oup discussions Some o he main hemes eme ging om he in e iews and FGDs we e pe cep ion and accep abili y o he supplemen a y oods as well as adhe ence o ea men and sha ing o he oods. As findings did no di e much, he p esen a ion o da a om bo h in e iews and FGDs has been combined. 5.5.1. Pe cep ions and o ganolep ic quali ies The supplemen a y oods we e e e ed o as “Yombdo”in Fig. 1. Flowcha o pa icipan s om baseline o one mon h o supplemen a ion. Table 2 Baseline cha ac e is ics o pa icipan s (n ¼1.609) by in e en ion g oup. P oduc CSB LNS Soy quali y Dehulled Isola e Dehulled Isola e Milk % 0% 8% 20% 0% 8% 20% 0% 8% 20% 0% 8% 20% n o child en 135 127 136 135 133 134 133 135 134 138 133 136 Age o child en (mon hs), mean (SD) 11.8 (4.7) 12.9 (4.7) 13.1 (5.0) 12.3 (5.0) 12.3 (4.3) 11.5 (4.6) 13.0 (4.7) 12.5 (5.2) 12.2 (4.4) 12.1 (5.0) 12.3 (5.1) 12.8 (5.1) Sex, masculin % (n) 41.5 (56) 44.9 (57) 48.5 (66) 44.4 (60) 44.4 (59) 43.3 (58) 51.9 (69) 46.7 (63) 46.3 (62) 42.2 (61) 46.6 (62) 41.9 (57) W/H Zsco e a admission, mean (SD) 2.2 (0.6) 2.3 (0.5) 2.2 (0.5) 2.2 (0.5) 2.2 (0.5) 2.2 (0.4) 2.3 (0.5) 2.2 (0.5) 2.2 (0.5) 2.3 (0.5) 2.2 (0.5) 2.1 (0.5) MUAC a admission, mean (SD) 121.8 (4.1) 122.8 (4.1) 123.0 (4.1) 122.4 (3.9) 122.8 (3.7) 122.7 (3.9) 123.1 (4.7) 122.7 (3.5) 122.3 (3.7) 122.5 (3.8) 122.5 (3.9) 122.9 (3.9) B eas eeding a admission % (n) 96.3 (130) 93.7 (119) 92.6 (125) 95.6 (129) 95.5 (127) 93.3 (125) 95.5 (126) 91.1 (123) 98.5 (132) 94.2 (130) 93.2 (124) 96.3 (131) Age o ca e ake (SD) 26.9 (6.4) 27.5 (6.2) 27.6 (6.3) 27.4 (6.3) 26.1 (6.5) 27.2 (5.6) 27.6 (5.6) 27.4 (6.9) 28.0 (7.0) 26.5 (6.7) 27.4 (5.9) 26.9 (6.1) Mo he absen % (n) 3.0 (4) 0.8 (1) 3.0 (4) 0.8 (1) 1.5 (2) 2.3 (3) 0.8 (1) 2.3 (3) 0 0.7 (1) 1.5 (2) 0.7 (1) Educa ional le el o mo he % (n) No educa ion 84.5 (114) 88.2 (112) 87.4 (118) 83.0 (112) 76.7 (102) 83.6 (112) 89.5 (119) 79.3 (107) 88.8 (119) 84.8 (117) 88.7 (118) 91.9 (124) P ima y 9.6 (13) 7.9 (10) 9.6 (13) 10.4 (14) 15.0 (20) 14.9 (20) 6.8 (9) 13.3 (18) 6.0 (8) 9.4 (13) 7.5 (10) 5.9 (8) Seconda y 5.2 (7) 3.9 (5) 2.2 (3) 6.7 (9) 8.3 (11) 1.5 (2) 3.7 (5) 5.9 (8) 5.2 (7) 5.1 (7) 3.8 (5) 2.2 (3) >Seconda y 0.7 (1) 0 0 0 0 00000.7(1)00 Unknown 0 0 0.8 (1) 0 0 0 0 1.5 (2) 0 0 0 0 Household membe s, mean (SD) 12.8 (8.2) 13.3 (8.4) 13.8 (7.7) 13.6 (9.5) 12.8 (8.0) 13.7 (9.6) 13.7 (9.3) 12.9 (9.6) 13.2 (6.9) 12.9 (7.9) 13.4 (8.2) 12.1 (7.0) A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e45 39 Moo  e which means “child wi h w inkled skin”, and is also a wo d used o desc ibe malnu i ion. They we e said o be gi en o ea child en om malnu i ion and/o illness o o s eng hen he heal h o he child, and ca e ake s exp essed a high le el o us in he abili ies o he supplemen s. I he ea s i [LNS] and i en e s in o his body, he powe o he supplemen elimina es he disease ha is in his body and cu es him. (33-yea old ca e ake o 7-mon hs old child) The CSB is eally good. The day o my inclusion my child was eally doing badly. When hey placed him on his back, he couldn' e en oll o e on his s omach, he couldn' e en open his eyes, and a he blood samples he nu se sea ched in ain. He was eally malnou ished, almos dying. Bu when I came back wo weeks la e , he was in good shape, you would almos say ha he was e- bo n (laughing). (FGD, La oden) As such, he supplemen s we e mos o en e e ed o as ood wi h medicinal p ope ies o medicine and he medicinal quali ies o bo h ypes o supplemen s we e o en highligh ed. Some said ha he supplemen s we e mo e medicine han ood o could no be compa ed o ood, because o hei medicinal e ec . Yes, i [CSB] is medicine; i is no o be compa ed o o he oods. (29- yea old ca e ake o 16-mon hs old child) The CSB mos ly ea s, so i is medicine. (FGD, La oden) I hink ha i [LNS] is medicine, e en hough i is a ood, i is mo e medicine han a ood … .. Because i cu es, i gi es good heal h. He was also ea ing be o e he inclusion, bu his heal h wasn' as good as i is oday. (33-yea old ca e ake o 7-mon hs old child) O he ca e ake s belie ed ha he supplemen s we e a combi- na ion o medicine and i amins. The [CSB] flou is a mix o medicine and i amins ha gi e he child appe i e so ha he ea s well. (FGD, Gonponsom) I hink i [LNS] is medicine; i is also i amins, which make child en fi and heal hy when hey ea i . (27-yea old ca e ake o 7- mon hs old child) Ne e heless, some o he ca e ake s did e e o he CSB as ood, mainly due o hei abili y o keep child en ull and hei hunge sa isfied. I [CSB] is a ood because i he child is ea ing i well, he is ed, he is ull and he b eas eeds less. (30-yea old ca e ake o 22-mon hs old child) S ill, he majo i y belie ed ha he CSB could no be compa ed o no mal oods. I am saying ha i [CSB] is a mix [o ood and medicine], because you would say ha i is flou , e en hough you ha e flou a home, bu hey a e no compa able. The flou o CSB ensu es heal h. (FGD, Gonponsom) When LNS we e e e ed o as ood, i was as “ ood ha ea s” and “mode n ood”mainly aimed a child en, because hey did no esemble he local ood. You know, he supplemen [LNS] is o he “whi e”child en [chil- d en o mode n imes], he elde ly hey don' know abou hese ypes o oods. I didn' exis be o e. I you gi e he supplemen o an Table 3 Es ima ed app ecia ion and o ganolep ic a ings o he supplemen s on a 5-poin hedonic scale a 1¼ e y good, 2 ¼good, 3 ¼neu al, 4 ¼bad, 5 ¼ e y bad. Child app ecia ion b Gene al app ecia ion Tas e Smell Tex u e Colou Es di 95%CI P- alue Es di 95%CI P- alue Es di 95%CI P- alue Es di 95%CI P- alue Es di 95%CI P- alue Es di 95%CI P- alue P oduc CSB . . . . . . LNS - 0.16 0.22; 0.10 <0.001 0.06 0.09; 0.02 0.004 0.03 0.02; 0.07 0.275 0.02 0.07; 0.03 0.367 0.002 0.03; 0.03 0.913 0.02 0.05; 0.01 0.146 Soy Dehulled . . . . . . Isola e 0.05 0.02; 0.12 0.139 0.003 0.04; 0.03 0.855 0.02 0.02; 0.07 0.329 0.03 0.02; 0.08 0.211 0.003 0.03; 0.03 0.847 0.01 .0.02; 0.04 0.666 Milk 0%. . .... 20% 0.04 0.12; 0.04 0.289 0.04 0.08; 0.01 0.129 0.04 0.02; 0.09 0.224 0.03 0.03; 0.09 0.360 0.02 0.05; 0.02 0.381 0.01 0.05; 0.02 0.509 50% 0.08 0.16; 0.01 0.025 0.05 0.10; 0.01 0.030 0.03 0.03; 0.08 0.328 0.002 0.06; 0.06 0.926 0.002 0.03; 0.04 0.891 0.002 0.04; 0.03 0.875 I alics a e used o highligh esul s wi h p- alues <0.05. a Mean a ings (SD): Child app ecia ion; 1.84 (0.70), Gene al app ecia ion; 1.74 (0.50), Tas e; 1.90 (0.50), Smell; 2.03 (0.55), Tex u e; 1.92 (0.35), Colou ; 1.90 (0.35). b A p oduc esoy in e ac ion was ound: CSB/soy isola e: es . di ; 0.15 (95% CI -0.07; 0.24), p ¼0.001. LNS/soy isola e: es . di . 0.06 (95%CI -0.15; 0.03), p ¼0.190. A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e4540 old woman, she would ell you ha she doesn' wan i . I is he child en oday ha ea (32-yea old ca e ake o 17-mon hs old child) The as e o he LNS was said o sui able o child en. …… i [LNS] is no o my as e, bu i [LNS] is sui able o my child (32-yea old ca e ake o 9- mon hs old child) Con a ily he as e o CSB was said o indica e ha i con ained medicine. yes, when as ing i [CSB], you know ha i con ains a lo o medicine o help he child o eco e (25-yea old ca e ake o 11- mon hs old child) Some ca e ake s said ha hey added suga o he CSB po idge o inc ease he child's consump ion o he p oduc s, and ha he swee ness o he flou disappea ed when adding wa e . O he s said ha he as e o he CSB po idge was oo swee o hei child. Ca e ake s o child en ecei ing LNS said ha he supplemen s we e bo h swee and sal y. A ew o he ca e ake s o child en ecei ing LNS, commen ed on he odo , bu said ha i did no a ec he consump ion, while some o he ca e ake s o child en ecei ing CSB said ha he odou o CSB was e y s ong and simila o ha o medicine. Howe e , while some said ha he s ong odou o medicine p e en ed he child en om consuming he supplemen , o he s said ha i dis- appea ed when making he po idge. My child is ea ing i [LNS] wi hou any p oblems. The smell doesn' bo he he ; she also hinks ha he as e is good. (29-yea old ca e ake o 20-mon hs old child) My child does no wan o d ink he [CSB] po idge … ... She only ea s a li le when I gi e i o he o suck on [flou un-p epa ed]. And when we asked he why, she said i was because i smelled. When I as ed i , I sensed ha he smell o medicine was s onge han he smell o he fl(FGD, Gonponsom) Occasionally, a bi e smell upon ecep ion o some o he a- ions o CSB was epo ed bo h by he si e s a and by se e al o he ca e ake s o child en ecei ing CSB. This did no pe ain o a pa icula supplemen o ba ch o supplemen . Mos o he ca e- ake s said ha i did no a ec he as e o he supplemen s and con inued eeding he CSB o hei child en. A ew ca e ake s desc ibed ha hei child en we e e using he supplemen s, whe he i was CSB o LNS. Howe e , e usal was epo ed o be due o he child a he han he quali ies o he supplemen s. I don' know i his [ he child) body is w ong o his ood [LNS].(20- yea old ca e ake o 8-mon hs old child) Madam, he child is oo complica ed (laughing). I is no jus he [CSB] po idge ha he e uses, he e en e uses o ea o he oods. (22-yea old ca e ake o 18-mon hs old child) The o e all app ecia ion o he supplemen s seemed o be influenced by he ac ha many o he ca e ake s had seen o he child en eco e ing om malnu i ion when ecei ing he sup- plemen s and ha ea men was ee and suppo ed by in e na- ional pa ne s. I was a luck ha my child was selec ed o ee ca e, so i was e y good o me. (30-yea old ca e ake o 19-mon hs old child) … . I is a g ea oppo uni y o pa icipa e in his kind o p og am, whe e whi e people a e esponsible. The e is no hing we can do i he child is ill, he e is nowhe e o go, and he e is no hing o do i he child is ill. Bu i he child is so lucky o be selec ed o he p og am o he whi e people, and i God ex ends his hands o g ace, he child will su ely eco e and he mo he can con inue wi h he cho es. (32-yea old ca e ake o 19-mon hs old child) Table 4 Managemen o supplemen s, ques ionnai es 1546 pa icipan s. P oduc CSB (n ¼766) LNS (N ¼780) P- alue Repo ed le o e s a he end o he day, % (n) 33.9 (257) 17.3 (134) <0.001 Quan i y le o e % (n) <hal 62.0 (155) 74.4 (96) <0.001 hal o mo e 37.2 (93) 25.6 (33) don' know 0.8 (2) 0 Managemen o le o e s h own ou 56.2 (146) 28.8 (38) <0.001 ea en by ano he child 39.2 (102) 63.6 (84) ea en by mo he 3.5 (9) 3.0 (4) o he 1.1 (3) 4.6 (6) Quan i y o consume % (n) Too much 2.7 (21) 2.6 (20) 0.029 Jus enough 94.5 (724) 88.7 (689) Too li le 2.7 (21) 8.6 (67) Don' know 0 0.1 (1) I alics a e used o highligh esul s wi h p- alues <0.05. Table 5 Pe cep ions o he supplemen , ques ionnai es 1546 child en and ca e ake s. P oduc CSB (N ¼766) LNS (n ¼780) P- alue How o cha ac e ise he supplemen % (n) ood o child en 12.9 (99) 10.0 (78) 0.148 medicine o child en 53.9 (413) 55.7 (432) ood o amily 0.3 (2) 0.1 (1) medicine o amily 0.4 (3) 0.8 (6) i amins 31.9 (244) 32.6 (253) o he /don' know 0.6 (5) 0.8 (6) The supplemen should be dis ibu ed % (n) only o child en 15.0 (115) 13.9 (108) 0.245 only o malnou ished child en 84.2 (644) 85.1 (661) o he en i e amily 0.5 (4) 0.6 (5) don' know 0.3 (2) 0.4 (3) Reason o gi ing he supplemen % (n) o eed child en 12.1 (93) 10.9 (85) 0.256 o eed he amily 0.8 (6) 1.2 (9) o ea malnou ished child en 86.8 (664) 87.6 (681) don' know 0.3 (2) 0.3 (2) A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e45 41 5.5.2. Pe cei ed ease o use Bo h CSB and LNS we e desc ibed as easy o use by he majo i y o he ca e ake s. The LNS we e highly app ecia ed due o he ac ha hey could be consumed in one single meal o sa ed o la e and he p epa a ion o he CSB was desc ibed as simple. Some men ioned he wo kload o p epa ing he CSB, bu said ha he e o s we e wo hwhile, conside ing he pu pose. I is no i esome [using he LNS]. When I wan o gi e him some- hing o ea , I si down and ake my ime o encou age him o ea , and when he is ull, I sa e he es un il i is ime o ea again. (34- yea old ca e ake o 7-mon hs old child) I is simple o use and simple o p epa e, ou cups o wa e and one cup o flou , make i boil some ime, i is easy o p epa e …… (29- yea old ca e ake o 16-mon hs old child) No, i [p epa a ion o CSB] is ok, as i is a ques ion o heal h; you ha e o do i , so ha ou child en a e in good heal h. (28-yea old ca e ake o 23-mon hs old child) Ne e heless, ca e ake s men ioned di ficul ies managing he CSB while also ha ing o a end he daily cho es especially in compa ison o LNS and especially du ing he season o field wo k. Some also epo ed ha hey se ed he flou unp epa ed o he child, o him/he o suck on ( he unp epa ed flou had a ex u e like cookie c umbs), which educed he need o p epa a ion. I [ he p epa a ion o CSB] is no di ficul , bu compa ed o he LNS i is no he same. Du ing he wo k in he fields you ha e o in e up you wo k, o make he po idge. Bu wi h he LNS, all you ha e o do is o wash he hands o he child and make a hole in he sache and gi e i o him o i you wan o eed him you sel , you si down and you gi e i o him. Wi h he LNS you can go o he mass a chu ch o o he ma ke , you can b ing he sache in you bag and gi e i o he child when you wan o. Bu wi h he CSB you can' go anywhe e; you ha e o espec he eeding hou s and make he po idge o he child.(FGD, La oden) Addi ionally he pe cei ed ease o use o he CSB was a ec ed by he child's consump ion o he supplemen . Especially when he child e uses o ea , you ell you sel , ha i he is no ea ing i , and you don' ha e much ime, you will no go h ough he ouble o making he po idge, as he will no e en ea i . (33-yea old ca e ake o 18-mon hs old child) I he child wan s o d ink he po idge, making he po idge is no a big p oblem. (FGD, La oden) The supplemen s had high p io i y in he daily die o he child, due o hei pe cei ed medicinal e ec . Because i [LNS] is medicine. Fi s you ha e o gi e him he medi- cine ha ea s him be o e gi ing him o he meals. (30-yea old ca e ake o 19-mon hs old child) I is impe a i e ha he akes his [CSB] po idge e e y day, because i is medicine. You fi s ha e o ea be o e hinking o gi ing o he oods. (22-yea old ca e ake o 18-mon hs old child) As soon as I wake up, I s a making he [CSB] po idge, be o e doing any hing else. Only a e ha ing se ed he po idge, I s a o do he household cho es. (FGD, Gonponsom) Howe e , in some cases i also a ec ed he consump ion o especially CSB in a nega i e way, as child en would e use hem, because hey hough ha hey we e medicine. This was mainly due o he ac ha he po idge was se ed wi h a spoon, which he child associa ed wi h medicine. No i is good, she has o as e he po idge o know ha i is ood, i no , she will no ake i , because she hinks ha i is medicine, especially because i is se ed wi h a spoon … . She was sick, and she ook a lo o medicine. This made he no like medicine. You ha e o s uggle o ge he o as e, so ha she knows ha i is po idge, be o e she accep s o ea i . (33-yea old ca e ake o 11- mon hs old child) The daily quan i y o consume was pe cei ed as adequa e. Ye , some ca e ake s epo ed ha ing di ficul ies ge ing hei child o finish hei meals. Many ca e ake s o child en ecei ing CSB e- po ed le o e s, while he majo i y o ca e ake s o child en ecei ing LNS said ha hei child en we e able o finish hei daily a ion in one o se e al meals h oughou he day. I is a lo , she has no been able o finish he quan i y I p epa e o he . (33-yea old ca e ake o 11-mon hs old child) He finishes he sache [o LNS] e e yday …… .. he has ne e had any di ficul ies finishing he supplemen (42-yea old ca e ake o 18- mon hs old child) In o de o educe le o e s o especially CSB, many ca e ake s epo ed se ing he CSB flou unp epa ed o he child o suck on o by p epa ing he CSB as wha hey called “couscous”, meaning a mo e iscous po idge (less wa e added). My child does no manage o finish he [CSB] po idge, bu once you gi e him he flou plain o ea , he can ea mo e han one measu e o flou . (FGD, Gonponsom) When hey ga e me he CSB flou s, he would no ea i when I made i . Bu i i is made like a couscous he ea s non-s op. Bu i I make i as po idge, i will las all day. (FGD, La oden) Reasons o ha ing le o e s we e epo ed o be mainly due o illness and he eby educed appe i e o because he child disliked he supplemen . 5.5.3. Sha ing o he supplemen s A majo i y o he ca e ake s said, ha hey did no sha e he supplemen . Howe e , some admi ed o gi ing he le o e s o o he child en in he household, i he child e used o finish he a ion. Only a ew admi ed o sha ing he supplemen wi h o he child en i hey we e a ound du ing eeding ime. Yes, when he e a e le o e s a e he meal, I gi e him [ he big b o he ] he emaining [o CSB]. (33-yea old ca e ake o 18- mon hs old child) … ..Some imes I ake a sache and gi e i o he child o my co-wi e, because she gi es he sache [o LNS] o my gi l. Bu o he han ha I don' gi e i o anyone. (29-yea old ca e ake o 20-mon hs old child) The main easons o sha ing was no o h ow away ood o i o he child en we e c ying and wan ing he supplemen . When asked i i was cul u ally accep able no o sha e he supplemen s, mos o he pa icipan s said, ha no sha ing was accep able o a leas a necessi y, in o de o ensu e he eco e y o he child. This was mainly due o he ac ha he supplemen s we e pe cei ed as medicine o a medical ea men . A.-S. Iuel-B ockdo e al. / Appe i e 99 (2016) 34e4542