Adrienne Clermont is a research associate at the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, and the author of ‘Market-Based Sales of Nutritional Products in Low-Income Settings: Acceptability and feasibility from consumer focus groups in Haiti’. The article is based on research from her thesis project for her Master of Science in Public Health (MSPH) in Human Nutrition and is published in the Sight and Life magazine, Focus on Food Culture edition.
The feature examines the distribution of lipid-based nutrient supplements (LNS), which, it says, have grown in popularity in recent years in low-income contexts and are currently distributed primarily through humanitarian assistance programs, the scope and duration of which are limited by the availability of donor funding. It considers the case of Haiti, a country with intensely high levels of poverty and food insecurity, asking if market-based sales of LNS could prove viable in this country; if so, they could provide a new and sustainable revenue stream for local LNS producers in addition to an affordable source of high-quality nutrition for low-income Haitians.
Clermont told Sight and Life that her experience in Haiti provided outcomes that were not only unexpected but on occasion heartbreaking, challenging, and inspiring.
Sight and Life magazine (SAL): Why did you choose this topic?
Adrienne Clermont (AC): Edesia, a US-based producer of ready-to-use foods (RUFs), nutritional products that combat malnutrition in low-income countries, had a grant to work with several partner organizations, including Meds & Foods for Kids (MFK), the RUF producer in Haiti, to look at whether it would be possible to sell RUFs on the market in Haiti. Up until now, MFK has produced RUFs for sale to non-governmental organisations (NGOs), schools, hospitals, and other organizations. It has never sold directly to consumers, however, which could allow these nutritional products to reach more people and have more of a positive impact. If sold at a price that covered all manufacturing and distribution costs, they could help subsidize MFK’s work with more underprivileged populations.
A whole team of Haiti-based researchers was involved in the project and used several research methods, including a quantitative survey and key informant interviews. I was asked to lead the qualitative research component, carrying out focus groups with low- and middle-income consumers to find out more about their food-purchasing habits, and their potential interest in an RUF product.
SAL: How did you collect your data?
AC: We conducted 19 focus groups in four cities across Haiti. These included (in separate groups) pregnant and lactating women, primary-school-age kids, and male and female caregivers of young children. I speak French fluently, but very limited Haitian Creole, so I sat in the back and listened while a Haitian colleague led the discussions. I was able to follow a bit, and being there gave a lot of context for when we translated the focus groups into English later on. It was fascinating to see the group dynamics, as well as get a glimpse into the lives of lower-middle class Haitians in a variety of circumstances. In each location, we spent some time traveling around the neighborhood to see the context, and to see what foods were for sale nearby (part of our objective was to understand the food landscape and competitor products that the RUF would face). Some of the focus groups were at schools, and others were at a health clinic in a slum, so we saw a lot of interesting places.
SAL: Are there any key moments you would like to share?
AC: One of the most interesting and fun parts of the focus groups were the taste tests. I brought hundreds of sample sachets of peanut-based RUF with me from Edesia’s factory in the US to Haiti, and during each focus group we were able to give each participant a sachet and get their feedback.
RUF is like thick, sugary peanut butter, so most people – especially kids – love it. Pretty much every single kid in our focus groups finished their sachet, tore the packaging apart, and licked it until every last speck of peanut paste was gone. It was heartbreaking to watch, because it gave an idea of how hungry most of these kids are most of the time.
Among the adults, most people liked the product, but there were some varied opinions. First, peanut butter is a hugely popular local product in Haiti, so everyone was comparing the RUF to mamba, which is Haitian peanut butter. They claimed they could taste that it was not made from Haitian peanuts, that the taste was ‘too weak,’ but I think that was mostly because RUF is mixed with a number of other ingredients (sugar, soy, dairy, oil, vitamin premix), so it does taste quite different from pure peanut butter. Some local peanut butter in Haiti is made with chili powder, so they recommended we make a ‘spicy’-flavored RUF to appeal to adults! Second, some pregnant women found the RUF off-putting because of their food sensitivities. In Haiti, people say that a woman’s food cravings in pregnancy are based on what the baby in the womb wants, so I guess some of those babies did not want peanut butter!
SAL: And any unexpected outcomes?
AC: I didn’t go into the study with any expectations about whether market-based sales of RUF would be feasible or not, so the ultimate conclusions of the study were a surprise to me. Essentially, what we found is that, although there is a huge need for healthy, nutritious snack foods in Haiti (most current snack foods are highly processed cookies and crackers with basically no nutritional value), and there is an existing system of small street vendors who could sell such a product to our target consumer groups, it would be practically impossible to produce the RUF at the price point that most Haitians would be able to pay.
Existing snack foods are incredibly cheap, and RUFs must be produced to international standards – things like vitamin premix, peanuts that are inspected for aflatoxin, and plastic packaging that is shelf-stable (even in Haiti’s tropical climate) for up to two years are expensive. And the sad reality is that most Haitians do not have the information to distinguish between ‘healthy’ and ‘unhealthy’ snack foods and, at the end of the day, need to prioritize putting food in their bellies over paying more for the most nutritious option. I believe Edesia and MFK are looking into production options that might allow RUFs to be produced at that price point in the future, but at the moment it’s not feasible.
SAL: Did your research help Edesia move forward with LNS products in Haiti?
AC: Edesia and, more importantly, MFK both continue to innovate in terms of new LNS products for Haiti. However, for the time being, they continue to focus on sales to humanitarian groups only, rather than market-based sales (the topic of my research).
SAL: What findings would you like to highlight?
AC: We spent quite a bit of time in the focus groups talking about women’s nutritional needs in pregnancy – what typical diets are, cultural beliefs about what should and shouldn’t be consumed during pregnancy pregnancy, and so on.
One interesting finding was that many women actually fear getting ‘too much’ nutrition in pregnancy, in the sense that they worry a very large baby will lead to a difficult, painful, or even life-threatening delivery. There is some foundation to this, in that women who are stunted (due to poor nutrition earlier in life) may have trouble delivering a large baby due to the smaller size of their pelvis. However, these women took this idea too far – several of our focus group participants reported refusing to take prenatal supplements (such as iron pills) because they didn’t want the baby to get too big. In fact, they believed the iron pills were actually a ‘scam’ carried out by doctors to make more money – that the doctor would give women pills to make the baby grow big, so the baby would have to be delivered by Cesarean section, an expensive procedure that the doctor could then charge for.
This is a sad commentary on the level of trust in the Haitian medical system! I have since seen this same fear of big babies resulting in Cesarean sections or dangerous childbirth in other qualitative research I’ve done in West Africa, which is interesting. It’s an area where better messaging (addressing this fear during antenatal care visits when iron pills are distributed) could really help to alleviate a problem, and encourage more women to take nutritional supplements in pregnancy.