Understanding Food Purchase Decisions in Low-income Populations

The Importance of the Consumer

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Dr Hannah Theobald, nutrition and country support manager of the Scaling Up Nutrition Business Network (SBN) and the Global Alliance for Improved Nutrition (GAIN)  is the author of “Consumer Insight for Improved Nutrition: Why consumer research is required to develop demand for nutritious foods among low-income consumers”, published in the ‘Focus on Food Culture’ edition of Sight and Life magazine.

Theobald’s expounds upon the SBN’s vision for more businesses to responsibly leverage consumer insight and data in their production of nutritious foods, particularly for low-income consumers, and its hopes that businesses will develop marketing and communications approaches making nutrition more exciting, relevant and aspirational to the consumer. 

“One third of the world’s population is consuming a poor diet, the world is facing a huge public health and economic challenge,” notes Theobald. “Improving the diets of more than two billion people requires, among other things, engaging food businesses to improve the nutritional content of foods and make nutritious foods more desirable. To reach the ‘bottom of the pyramid’, food businesses need to develop a deep understanding of low-income consumers and their food purchase decisions.”

A bit of background information, the Scaling Up Nutrition (SUN) Movement was established in 2010 and supports national leadership and collective action to scale up nutrition. The SBN is one of four global networks that support SUN countries, along with the United Nations (UN), civil society and donor networks. It is convened by GAIN and the UN World Food Programme (WFP), but is also further supported by an advisory group comprising senior business leaders. The SBN advocates for and supports business investment in nutrition in order to help reduce all forms of malnutrition through innovation and responsible and sustainable initiatives, actions and operations.

The SBN’s wider remit is to facilitate partnerships and linkages with organizations that provide technical assistance, business development support and access to finance, in order to support business to better address malnutrition in all forms. As such, where possible, SBN undertakes and/or collates consumer and market research and shares findings with its business members at the national level.

In this interview, Theobald shares how SBN advocates and supports businesses to act on the issue surrounding malnutrition. The SBN’s Global Coordinator, Jonathan Tench; Uduak Igbeka, the Team Lead of SBN Nigeria, which is convened by GAIN; and Ralf Siwiti, Programme Manager, SBN Zambia, which is convened by the WFP also contributed to the Q&A session. 

Sight and Life (SAL): Tell us a little bit about your background, and how you got involved in Scaling-Up Nutrition Network.

Hannah Theobald (HT): I’m a BSc and PhD qualified nutritionist, and have spent the majority of my career working as a nutritionist in the private sector, mainly focusing on emerging markets. In the last few roles within business I was involved in more corporate social responsibility (CSR) work. I’d been thinking about working in international development for some time so, when the opportunity arose, I took it. I had been aware of and inspired by the work of GAIN and the SUN Business Network for a while. Working on the SBN has been a great way of utilizing my nutrition and business background for social good and sustainable nutrition improvement.

Uduak Igbeka (UI): My background is in agricultural economics. I have been working at GAIN for six years now, focusing on regulatory agencies in industry on a food fortification program before the opportunity to join the SBN team presented itself. It was quite a natural fit, seeing as I had been working closely with business in Nigeria already. I found the opportunity to engage with businesses beyond the food sector exceptionally exciting.

Ralf Siwiti (RS): I am a marketer at heart. My career has taken me from managing relationships in sales to developing marketing communications campaigns for large multinationals in the food industry, as well as non-profit campaigns. My journey with the SUN Movement began with participation as a representative of a well-known consumer goods company at the launch of the SUN Business Network in Zambia in November 2014. Five months later, I was at the helm of this budding project, which has now developed into one of the most successful SUN country networks working to generate private sector investment in nutrition. I am currently leading SBN Zambia into its next phase, which will see it directing focus on making nutrition aspirational for consumers in Zambia.

SAL: What are the SBN’s main objectives?

HT: As the world’s only dedicated, global platform for business and nutrition, we have three main objectives. First, to mobilize business to contribute to reducing malnutrition in all forms. Secondly, we aim to make nutrition more aspirational, accessible, affordable – and available to the consumer. Finally, we are building the case for greater business engagement in nutrition amongst all stakeholders. We achieve this with the support of more than 400 members, which includes both multinational and national companies that are committed to improving nutrition throughout the world.

SAL: How do other stakeholders, who are part of the SUN network, perceive consumer research? 

UI: In Nigeria, the research that was shared with business was commissioned by the Bill & Melinda Gates Foundation, and was originally intended for civil society and shared with them in the first instance. Because formative research is a big part of development, it is perceived that this type of research would help in shaping the development of more nutritious product for target populations in Nigeria.

RS: In Zambia, most stakeholders in the SUN network hold a positive view of consumer research and insight, as undertaken by the national SBN. The country has a widespread lack of data, including that on consumers. As a result, most sectors are eager to learn of the availability of usable data. Consumer insights form an increasingly powerful tool in terms of the implementation of programmes, particularly those relating to behaviour change communications (BCC).

SAL: What challenges are you faced with, to have others − both in and out of the SUN network − accept consumer research and apply the work?

Jonathan Tench (JT): Businesses face two common challenges when it comes to scaling up investment and action on nutrition. First, investment in nutrition is seen to be too expensive – returns on investment can be low if scale is also low and this can be seen as risky by business and investors alike. Second, there is little demand for nutrition at present, especially from low-income consumers, so it is hard for companies to make a case for investing more, as they don’t see a market. There’s also quite a poor understanding of what we mean by nutrition, which in part explains the low demand for nutritious foods. It’s important to do more to raise consumer awareness; we have to educate both consumers and businesses about nutrition.  

There are lots of ways that companies globally address this issue, alone or as part of public-private partnerships, for example around consumer behavior change. We want to encourage more of that type of action and partnership. Businesses can take other actions to raise awareness of and demand for nutritious foods, such as employing social marketing techniques where consumers are taught about the benefits of nutrition. Companies are often very good at marketing aspiration and employ a huge range of marketing strategies, so we’d be keen for businesses to employ these skills to make nutrition more aspirational and desirable.  

RS: The use of the term consumer can sometimes be interpreted as an attempt to commercially exploit the vulnerable. It is often important to highlight the fact that vulnerable people, or so-called beneficiaries of development programmes, are still capable of making choices. The choices they make can be a huge factor in attempts to support them and this is sometimes ignored in development programmes. The sensitization of stakeholders is important in relation to the need, use, and application of consumer insights as, by the nature of most development work, the consumer is often seen as a beneficiary who is vulnerable and must be protected.

UI: Businesses in Nigeria have found the information very useful for identifying product development opportunities. They find the information most useful where a business opportunity also addresses a public health need. Having access to market data through SBN provides access to a resource that many SMEs cannot afford. It helps stimulate innovation, and helps business better understand the consumer.   

SAL: What do you find most exciting and challenging in your work − and what do you hope to see in future?

HT: As a nutritionist from a private sector background, the need to understand the consumer well has been instilled in me. Before joining GAIN and the SBN, I therefore had an understanding of how consumer insight worked and the important role that it plays in product development and communication. It was very important for the network to get involved in this in order to help the Network develop effective consumer awareness campaigns and support business to deliver sustainable nutrition solutions. For example, in Tanzania, we didn’t understand the level of awareness of food fortification. Now that we do, we have a good understanding of consumer’s beliefs and knowledge it will be a lot easier to tailor messages around fortification.

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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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