Uncovering Nutritional Solutions in Haiti

A researcher's viewpoint

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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. 

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Why Ethnographic Research?

Insight behind gathering research data from a cultural perspective

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Dr Eva C Monterrosa is the senior scientific manager at Sight and Life and the co-author, with Prof Gretel H Pelto, graduate professor at Cornell University, Ithaca, of “The Mother-Child Food Relationship in the Study of Infant and Young Child Feeding Practices”, published in the ‘Focus on Food Culture’ edition of Sight and Life magazine. This article shines a light on how biology and culture come together at the level of the diet by reviewing infant and young child feeding (IYCF) practices. Far from ‘story-telling’, Dr Monterrosa says research that incorporates a cultural perspective achieves two objectives: First, to generate explanatory frameworks that help us understand and generate hypotheses about health behaviors; and, second, to design programs to improve behaviors.

When we spoke with Dr Monterrosa about how she came to this topic of research, she had some stimulating answers:

Sight and Life magazine (SAL): Why did you choose this topic – what inspired it?

Eva Monterrosa (EM): In my opinion, public health nutrition research design is focused on getting the results we want – often at the expense of understanding ‘how’ results were achieved. But it is precisely the ‘how’ (or the ‘black box’) that can help us design programs that achieve our goals. A successful outcome in one setting might not lead to success when it is replicated in a different context. By context, I don’t just mean a different country. Even replication in the the same type of institution, such as a hospital or clinic, can be a challenge. In essence, we must understand the context to know what factors are driving our results, and how to adapt interventions to fit our context. Ethnographic research gives us the tools to do this.

Guatemala research
Dr Monterrosa and colleague researcher watching mothers in Guatemala make pap food for their young children. Photo credit Eva Monterrosa

 

SAL: What challenges do you face when doing this type of research?

EM: I think my greatest challenge is people telling me, often not in a nice way, that my research is ‘story telling’, or worse yet saying that what I do is ‘not research’. This however, speaks to another predisposition in nutrition science: That research is only valid if it uses a randomized trial design , or uses complex statistical procedures. Don’t get me wrong – I can hold my weight when it comes to running a complex analysis of longitudinal data, but I understand this work’s limitations. Moreover, when you deal with food and eating habits, these are complex social phenomena that cannot be reducible simply to numbers.

In the research Prof Pelto and I share in the article, we use ethnographic methods, such as observations, interviews, and other cognitive elicitation techniques, including free listing, and card-sorting exercises. The selection of the methods is always guided by a research question. One must skillfully apply interviewing techniques, including careful wording of questions and precise ordering to reduce reporting bias. Lastly, a rigorous analysis of the text data is necessary to elicit solid insights based on the data.

SAL: What has been the most surprising result or outcome from your research?

EM: When study participants ask clarifying questions – their questions lead to all sorts of wonderful discoveries. I recall from my Mexico work that I asked one of my first participants: ‘What meals do you prepare at home?’ And she asked, ‘Meals for whom? My family or my children?’ and this was an unexpected answer that led to a wonderful discovery of child-appropriate meals, which added another dimension to our data analysis. We went from just describing complementary feeding practices to understanding how mothers and children inhabit the same ‘eating space’. It was fascinating!

SAL: Why is applied ethnographic research for nutrition science important?

EM: Two pieces are featured in this issue of Sight and Life magazine, because I want our readers to understand the explanatory power of ethnographic methods, and how this work can help their scientific inquiries or programs. It is not about the biological perspective versus the cultural perspective. That is counterproductive. We need a holistic view of nutrition science.

SAL: Do you think people will listen?

EM: I hope so! Prof Pelto developed the biocultural framework in the late 1970s as a framework to examine the different domains that in interaction determine dietary and eating practices. Today, there is a new generation of scientists seeking to address the complexity of eating practices. We are seeing a rise in training on mixed-method designs, excellent research question(s), solid training in ethnographic methods, and the analytical procedures to elucidate patterns in the data.

Guatemala
As a guest, people are always curious as to why you visit their communities. This bright, young girl didn’t leave my side the whole time we were conducting focus group discussions in her village. Photo credit Eva Monterrosa

SAL: How is your research used?

EM: Much of the work that we do is used to develop programs. A lot of the nutrition research that draws on the biological perspective has an impact on the policy sphere, for example, in helping to set recommendations of vitamin A or calcium. As for the ‘how’ to develop programs for administering vitamin A or calcium? That is a whole different research phase, but it is the space that our research inhabits.

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