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Background: Multiple specialized nutritious food options are programmed for supplementation in humanitarian and development settings. However, comparative cost-effectiveness evidence is lacking, let alone incorporation of perspectives from uncompensated stakeholders. A Burkina Faso trial evaluated the cost-effectiveness of Corn Soy Blend Plus w/ oil (CSB+ w/oil, reference arm), Corn Soy Whey Blend w/oil (CSWB w/oil), Super Cereal Plus (SC+), and Ready-to-Use Supplementary Food (RUSF) in reducing stunting and wasting among children 6-23 months old. This paper presents cost-effectiveness findings from multiple stakeholders' perspectives, including caregivers and program volunteers.Methods: An activity-based costing with ingredients approach was used to summarize cost of the 18-month-long blanket supplementary feeding for each enrolled child (in 2018 USD). Time data were collected using self-reported and observational instruments. Cost-effectiveness relative to CSB+ w/oil assessed incremental cost per enrolled child against incremental outcomes: prevalence of stunting at 23 months of age and number of months of wasting. Two combined perspectives were compared: program (donor, implementer, and volunteer) versus program and caregiver (adding caregiver).Results: A total of 6112 children were enrolled. While similar effectiveness was found in three arms (CSWB w/oil was less effective), costs differed. Product cost and caregiver time to prepare study foods were major drivers of cross-arm cost differences from the respective combined perspective. The two major drivers were used to construct uncertainty ranges of cost per enrolled child from program and caregiver perspective: $317 ($279- $355) in CSB+ w/oil, $350 ($327- $373) in CSWB w/oil, $387 ($371- $403) in RUSF, and $434 ($365- $503) in SC+. Cost from program and caregiver perspective was a substantial increase from program perspective. CSB+ w/oil was most cost-effective in reducing stunting and wasting, and this main finding was robust to changing perspectives and all corresponding sensitivity analyses when uncompensated time was valued at minimum wage ($0.36/h). The break-even point for uncompensated time valuation is >$0.84/h, where RUSF became the most cost-effective from the program and caregiver perspective. Relative cost-effectiveness rankings among the other three arms depended on choice of perspectives, and were sensitive to values assigned to product cost, international freight cost, opportunity cost of time, and outcomes of a hypothetical control. Volunteer opportunity cost did not affect arm comparisons, but lack of compensation resulted in negative financial consequences for caregivers.Conclusions: Evaluating cost-effectiveness by incorporating uncompensated stakeholders provided crucial implementation insights around nutrition products and programming.Trial Registration: Trial registration number: NCT02071563. Name of registry: ClinicalTrials.gov URL of registry: https://clinicaltrials.gov/ct2/show/NCT02071563?type=Intr&cond=Malnutrition&cntry=BF&draw=2&rank=9 Date of registration: February 26, 2014. Date of enrollment of first participant: July 2014. [ABSTRACT FROM AUTHOR]

Background: This study assessed the association of remuneration systems of paid-for-performance Accredited Social Health Activists (ASHAs) and salaried Anganwadi workers (AWWs) on seven maternal health outcomes in four states in India: Andhra Pradesh (AP), Chhattisgarh, Odisha (Orissa), and Uttar Pradesh (UP).Methods: The cross-sectional study surveyed mothers of children aged 6-23 months. A total of 3455 mothers were selected via multistage cluster sampling. The seven health outcomes related to the community health worker (CHW) visits were: institutional delivery, complete immunization, exclusive breastfeeding for six months, timely introduction of complementary feeding, continued breastfeeding during child's illness, handwashing, and awareness of Nutrition and Health Days (NHDs).Results: The results varied by state. Mothers who received ASHA visits were significantly less likely to have an institutional delivery, timely introduction of complementary feeding, awareness of Nutrition and Health Days (NHDs), proper handwashing, and exclusive breastfeeding for the first six months in at least one of the four states. Conversely, AWW's home visits were positively predictive of the following health outcomes in certain states: complete immunization for index child, continued breastfeeding during the child's illness, handwashing, and awareness of NHDs.Conclusions: ASHAs' home visits were not more strongly associated with health outcomes for which they were paid than outcomes for which they were unpaid. AWWs' home visits were positively associated with awareness of NHDs, and associations varied for other recommended health behaviors. Further research could elucidate the causes for successes and failures of CHW programs in different states of India. [ABSTRACT FROM AUTHOR]

Background: Many organizations seek to alleviate poverty in the developing world, often focusing their interventions on women. The role, status, and education of women are fundamentally important facets of development. Thus, understanding the interaction of women's educational level and the response to interventions is important. Therefore, we examined the impact of educational level of household adults on responses to a livestock-based community intervention. Methods: Six pair-matched communities in 3 districts of Nepal (Chitwan/Nawalparasi/Nuwakot), were randomly assigned to receive community development activities via women's self-help groups at baseline or 1 year later. At 6 intervals over 48 months, a 125- item questionnaire addressing family demographics and child health/nutrition was completed in each household, plus child growth monitoring. Results were analyzed in relation to the highest education attained by any woman in the household, the child's mother, men, or any other adult in the household. Results: Outcomes (wealth, water/toilet availability, child diet diversity and growth) all significantly related to adult education. However, notable differences were found comparing the impact of men's and women's education. Percent change in wealth score was significant only in households where women had primary or secondary education (respectively, p = .0009 and p < .0001). Increased soap use related only to women's education (p < .0001). When adjusted for group assignment, baseline income, wealth, and animal scores, higher women's education was significantly associated with increased household wealth (p < .0001), better child height-for-age z scores (HAZ, p = .005), and improved child diet diversity (p = .01). Higher mother's education predicted better child HAZ (primary, p = .01, secondary, p = .03) and diet diversity (primary, p = .05, secondary, p < .0001). Higher men's education was significantly associated with household wealth (p = .02) and child diet diversity (p = .04), but not HAZ; higher education of any household member was associated only with household wealth (p < .0001). Moreover, households where the mother's education was better than the best-educated man also were significantly more likely to have children with better HAZ and dietary diversity (p = .03, p < .0001). Thus, the educational level of women and mothers had the broadest impact on child outcome variables. Conclusions: Household characteristics vary among participants in most community development projects. Of these, adult education likely mediates response to the inputs provided by the intervention. Particularly in interventions directed towards women, better education may enhance the ability of households to put interventions into practice, thus improving wealth, hygiene, and child diet and growth indices. [ABSTRACT FROM AUTHOR]

Background: In 2014, an intervention aimed at increasing the oil in corn soy blend (CSB) porridge prepared by caregivers of children with moderate acute malnutrition was implemented in Southern Malawi. This analysis describes the flow of key messages delivered through the Care Group model during this intervention.Methods: The intervention provided a supplementary food ration of CSB and oil and used a Care Group model in which healthcare workers were trained to deliver social and behavior change communication (SBCC) to care group volunteers who then delivered messages to caregivers of beneficiary children. Healthcare workers also delivered messages to caregivers directly. Interviews and focus groups were conducted with all three groups in order to determine the exchange of key messages about ingredient use, storage, and purpose, which were analyzed descriptively.Results: Analysis of SBCC flow and information exchange showed that 100% of caregivers reported learning about the amounts of oil and CSB to use while preparing porridge and over 90% of caregivers, healthcare workers, and care group volunteers reported talking about it. Focus groups confirmed an effective flow of communication among these three groups.Conclusion: This analysis evaluated the flow of key SBCC messages through multiple, overlapping lines of communication among healthcare workers, care group volunteers, and caregivers; the effective transmission of these SBCC messages through this model may contribute to the success of a supplementary feeding intervention program.Trial Registration: The study was registered at ClinicalTrials.gov ( NCT01873196 ). [ABSTRACT FROM AUTHOR]