Formative research for the development of a ... - The iLiNS Project

Formative research for the development elopmentof a market-based home fortificationprogram for young children in NigerKatie TrippInternational Micronutrient Malnutrition Preventionand Control (IMMPaCt) ProgramNutrition BranchDivision i i of Nutrition, Physical Activity, it and ObesityNCCDPHP

Niger• Formative research• Home fortification intervention• Market based• Children 6-24 months• CDC/UNICEF cooperative agreement• Collaborators– CDC, C, UNICEF, HKI, Nutriset, Hexagon

Key health and nutritionindicators among childrenin Niger•198 per 1000 mortality rate

Objectives of formative phase• Describe complementary feeding practices• Evaluate acceptability of Sprinkles andNutributter– Pick one product to pilot• Assess feasibility of a market basedapproach– Availability of resources; willingness to purchase– Perceived effects and importance of product– Possible distribution mechanisms

Location 1: Niamey – urban, Djerma ethnicityNigerGamkalley (industrial)Goudel (peri-urban)

Location 2: Doutchi – rural, Hausa ethnicityDoutchi city (town)Soucoucoutane (rural village)

Qualitative Data CollectionTwo main components of the formative work1) Interviews with primary & secondary audiences2) 4 week home study• Understand families experiences using products

• Focus group discussionsInterviews– Target groups: mothers, fathers, and grandmothers ofchildren 6-24 months• Key informant interviews– Mothers who used products (4 wk study)– Mothers of children with anemia– Traditional healers– Health workers• A total t of 28 interview i guides were developedd

4 week home study• 20 mothers of children 6-24 months ineachofthe4sites– 80 in all 4 sitesDoutchi: 1 product only (daily use)–Sprinkles or Nutributter–10 get Sprinkles; 10 get Nutributter–4 weeks of 1 product–Longer time to see changes, barriers to arise, etc.–Interview at enrollment, midpoint, and endpoint

4 week home study y( (cont).• Niamey: 2 products (daily use)– Crossover design– Sprinkles and Nutributter– 2 weeks of each product– Direct comparison of products– 10 start with Sprinkles and 10 with Nutributter– Interview at enrollment + supply of 1st product– Interview at midpoint + supply of 2 nd product– Interview at endpoint

Data collection completed• July to November 2009• 84 FGD with mothers, fathers, andgrandmothers• 80 mothers enrolled in 4 week study– 77 mothers completed

Main results

Perceived positive effects• Same effects for Sprinkles and Nutributter• Increased appetiteBefore I bought [my daughter] boule for 25 CFA(US0.06) for the whole day, but with the use ofSprinkles she eats boule for 50 CFA ($0.12).• Weight gainAt first when she was 5 months she weighed 3kg.Then [my husband] did not pick her up because shewas all lean. But now since she had gained weight healways picks her up.• Increased energy, strength• More interaction

Negative effects• Almost no one disliked either product• No perceived negative effects• Stool changes/diarrhea not perceived as negativeeffect– Mothers aware may see changes in stool so notconcerned

Barriers to use and concerns• No barriers to use for Nutributter• Barrier to use of Sprinkles – need foodWhen there is no boule, I do not give her Sprinkles• Very few had concerns about products– Mixed emotion about increased appetiteWe want you to bring us the necessary means [food]to feed our children…because Sprinkles gave moreappetite to my child. He ate a lot lately l and he asks toeat at all hours even the night and we don't alwayshave food in order to feed them.

Acceptability of the products• Both Sprinkles and Nutributter were acceptableI say to you, that I am very happy to have been givenSprinkles for my child. The whole family appreciates thechanges which occurred with my child …All that I want to say is to thank you for having given oury y g gchildren these very important foods [Nutributter]. Really,we saw its importance and we appreciate it a lot.

Product preference• 73% prefer Nutributter• 68% would buy NB over SP if available in themarket place• Reasons for preferring Nutributter:– Child liked sweet taste– Can mix with food or give direct– Child is able to feed himself• Reasons for preferring Sprinkles:– Can give to the child without him knowing– Not sweet so can mix with wider variety foods– Cheaper than Nutributter

Intention to use and reported use of• Intention to use–MixNutributter• Actual use (observed at midpoint i interview)i 54% gave NB directlyMain reasons for direct feeding– Child refused boule with NB– Child preferred NB directly– Boule not finished, NB wasted– Ease for mother

Sharing and pressure to share• Pressure to share was more intense inDoutchi– other households members– neighbors• 5 out of 77 reported sharing (NB and SP)• 2 households reported product was stolen

• SprinklesWillingness and ability to purchase– Niamey median = 50 CFA ($0.11 – range $0.05 - $1.05)– Doutchi median = 25 CFA ($0.06 – range $0.02 - $0.73)– 98% would purchase daily at 15 CFA ($0.03)• Nutributter– Niamey median = 100 CFA ($0.22 – range $0.05 05 - $1.05)– Doutchi median = 50 CFA ($0.11 – range $0.02 - $0.63)– 95% would purchase daily at 35 CFA ($0.05)• Similar results from focus groups

Limitations• Results not generalizable• Multiple translations• Products given for free in 4 week study;intent is to sell

Strengths• Rigorous methodology• Data from rural and urban areas• Multiple types of informants• Extensive formative work for programdevelopment

Recommendations• A market based or subsidized systemshould be feasible– free distribution for most vulnerable• NB is the preferred product– Most acceptable– Nutritionally beneficial

Acknowledgments – Niger project• CDC• Helen Keller International– Maria Elena Jefferds– Rafael Flores– Issa Bagurbi– Ken Brown– Cria Perrine– Hamani Harouni– Marily Knierieman• UNICEF– Farah Ali– Eric Ategbo– Nita Dalmiya– Gwen Desplats– Roland Kupka– Arnold Timmer• Emory University– Becky Hartz• Nutriset– Virginie Claeyssens– Mamane Zeilani• Hexagon– Vikram Kelkar• Independent consultant– Pascal de Campos• All participants i and field team

Thank you! Na gode! Merci!ktripp@cdc.gov• The findings and conclusions in this presentation are those of the author and do notnecessarily represent the official position of the Centers for Disease Control and Prevention.

Additional slides

Common complementary food - bouleMillet Pounded millet paste Boule• Usually first complementary food given• Out for 1–2 days for family to eat at will• Some days may be only food in poor householdsSource: Focus groups - mothers

Child feeding practices• Give liquids and other foods at 3–6 months• Other complementary foods– Oranges, mango, mashed beans, and solani (yogurt)• By 7–12 months eating family dish• No difference in how boys and girls fed– Except Soucoucoutane: boys given family mealseveral months later than girlsSource: Focus groups – mothers, fathers, and grandmothers

No: Topic Target group Number of focusgroups in each siteNumbers of focusgroups in all sitesGuide 1 Health and nutrition Mothers of children 6-23 mo 3 12Guide 2 Household dynamics Mothers of children 6-23 mo 3 12Guide 3 Reactions to products Mothers of children 6-23 mo 3 12Guide 4Health, nutrition, and householddynamicsFathers of children 6-23 mo 3 12Guide 5 Reactions to products Fathers of children 6-23 mo 3 12Guide 6Health, nutrition, and householdGrandmothers of children 6-23 mo 3 12dynamicsGuide 7 Reactions to products Grandmothers of children 6-23 mo 3 12Total 21 84

Nutributter is a peanut based spread thatis made from peanuts, oil, milk powderand sugar. It also contains severalvitamins and minerals. Nutributter caneither be eaten on its own or it can bemixed into food. Nutributter has beenused in several countries to improve thehealth of children, to increase theirappetite and activity and to preventvitamin and mineral deficiencies, such aslow blood.