Focused Ethnographic Study of Infant and Young Child Feeding 6-23 Months: Behaviours, Beliefs, Contexts and Environments.

Manual on Conducting the Study, Analyzing the Results, and Writing a Report

Gretel H. Pelto, Margaret Armar-Klemesu, Faith M. Thuita

PROTOCOL II. CAREGIVER RESPONDENT INTERVIEW

CR Module 1: Demographic and SES Characteristics

CR Module 2: Twenty Four Hour Recall for index Child

CR Module 3: Food preparation and feeding behavior

CR Module 4 Guided discussion about perceptions of value dimensions

CR Module 5: Factors that influence what you feed your IYC

CR Module 6: Perceptions about micronutrient supplements and fortification of infant foods

CR Module 7: Estimated Weekly Food Expenditures

CR Module 8: Food and feeding-related problems/challenges

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Caregiver Respondent Module 1

Demographic and SES Characteristics

Background

For the purposes of this study it is important to ensure that the sample of caregiver- respondents reflects the kinds of households the proposed complementary food product is intended to reach. Part of this assurance is achieved by sampling in appropriate locations, but it also needs to be confirmed by getting information about the characteristics of the caregivers and their households. Because the sample is small, and not selected through a strict random sampling technique, statistical comparisons are not appropriate, However, it is still necessary to describe the sample’s demographic and socio-economic characteristics. Also, in examining the results for similarities and differences in the women’s responses, it is useful to know more about them, such as whether they have more versus less formal education or whether they are managing small versus large households.

The data collection in this first module involves 4 separate topics:

1. Confirming the age of the index child

2. Household composition, with demographic characteristics

3. Indicators of economic status through living condition measures

4. Caregiver’s estimate of total monthly household income

The methods that are used in this module are primarily open-ended (not precoded) questions, but they also include pre-coded items in the “indicators of economic status section.

Procedures

1. Introduce this module by explaining to the caregiver that before you start discussing specifics about child feeding and care, you would like to get some background information about herself and her family. Reassure her, as you already did when you her informed consent, that you will keep this information confidential, and that you need it only to understand the ways in which her household is similar or different from other households in the community.

2. Take out a clean CR Module 1. Part A. Household Composition Recording Form and fill in the top lines. If appropriate to local conditions, ask for a telephone number in case you need to contact the caregiver again. Confirm child age with birth date. Then proceed to fill in the demographic information, starting with the caregiver herself. You can say:

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“I’d like to ask you a few questions about who lives here in this household, starting with you yourself.

Work across the row, eliminating questions that are not appropriate (e.g. education or occupation of children below school age). For “occupation” and “hours per week of work” of the caregiver, try to get an accurate picture of her current schedule of activities. Be sure to make full notes. For example if she is trained as a hairdresser but is not currently working because of her baby, make a note about this. If she does other people’s laundry but brings it home make a note of this work arrangement. If she is working regularly away from home, be sure to ask about alternate care arrangements and record the information on the continuation sheet (page 2) for this form. Find out who takes care of the IYC, where the IYC is taken care of, approximate number of hours per work the IYC is in the this care.

3. The next step is to ask about the living conditions measures. As part of the preparation for conducting the study, you will already have created a form to record this information. It should be titled: “ CR Module 1 Part B. Living Conditions Recording Form.” (See section on preparing for caregiver-respondent interviews). Ask about each of the items on the list and record the answers on the CR Module 1 Part B. Living Conditions Recording Form.

4. The last item in Module 1 is to ask the caregiver if she knows approximately how much income the household receives each month. If she says she does, you can then ask her about how much that is. If she is literate you can hand her a card, with income brackets, indicated by letter, and ask her which bracket her household falls in to. Depending on the cultural situation, many women will not know how much their husbands/partners earn, which is why it is best to ask first whether she knows. If she does not, it is best to make some non-committal reassurance, such as “that’s alright; now let’s start talking about feeding and taking care of children.”

Record the caregiver’s answer for monthly income on the bottom of the Part B form.

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Caregiver Respondent Module 2

Twenty Four Hour Recall for Index Child

Background. The purpose of this module is to generate a picture of caregiver behaviors in relation to IYC feeding. It uses a qualitative 24 hour recall to establish a “sample” of what a child is currently eating and his/her feeding schedule. Of course, a single 24-hour recall is not a full representation of what a child receives, but it is used on the assumption that feeding practices at this period are relatively stable from day to day and that caregivers know and can remember what they fed their child the day before the interview.

This module is also an opportunity to ask whether the child is being given a nutritional supplement.

This module uses the “open-ended questions with guided discussion” method.

Procedures 1. Take a blank 24-hour recall recording form. You can start by saying:

“ I’d like to ask about what your baby/child eats on ordinary day. Was yesterday an ordinary or usual day? (If not, ask why and then ask whether the previous day was more ordinary.)

“To start with, about what time did the baby wake up? Did he/she breastfeed when he first woke up? (Do not ask this question if the baby isn’t breastfed.)

“What was the first food he ate? About what time was it when you gave (name) (first item)”?

2. Record the name of the food item, exactly as the mother gives it to you. Then ask her more specific questions to be sure that you know what it was. At this point do not ask her how the food was prepared because you are going to ask her that in the next module. But you want to be sure that you know what the food is. For example, if she says “cereal” this is too vague and you have to ask what kind of cereal it was. If it is a commercial food be sure to ask what brand.

3. Record the answer on the 24-hour recall form. Then continue asking for the next food(s) and the time the child ate it. After each item ask whether the child also had something to drink and record the answer. In the case of working mothers, be sure to probe for what the mother thinks the baby received from an alternate caregiver or at the crèche.

4. When the mother says that’s the last thing the baby ate yesterday, get closure by saying “So then the baby went to sleep for the night and didn’t eat anything more until this

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morning?” Then ask, only for the breastfed child, “Do you remember about how many times your baby breastfed yesterday?”

5. Record the answer on the recording form.

6. Ask about supplements. You can say, “Apart from foods (and breastmilk, if still breastfed) did you give your baby/child anything else for his nutrition or health?

Record her answer, and if yes, ask for the name of the preparation.

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Caregiver Respondent Module 3.

F ood preparation and feeding behavior

Background

Information on what infants and young children are fed is an important aspect of describing current complementary feeding practices, but it is only part of the data that are required to obtain a picture of caregivers’ practices. Of equal importance is information on food preparation and feeding behaviors, as these play a major role in how they will respond to new products. The purpose of this module is to collect information on a number of features of food preparation and feeding. The module also provides an opportunity to learn about caregivers’ views about adding something to a child’s food after it has been prepared. This is important for assessing nutrient supplements that are intended to be used in conjunction with infant and young child foods.

This module uses the “open-ended questions with guided discussion method.”

Procedures

Part 1. Twenty-four hour recall preparation and behaviors

1. Keep the 24 hour recall form in front of you, and take a set of clean CR Module 3 Recording Forms. Write the name of the first food on the top of a sheet. Ask all of the questions on the form, but remember this is a guided discussion, not a simple question and answer exercise. Encourage the caregiver to discuss each food, and ask further questions to probe for details. You can modify the order in which you ask the probing questions, if that seems appropriate given the flow of information.

2. You can introduce the discussion by explaining: “I’d like to learn more about the foods you feed your baby. You said that yesterday morning the first thing you gave your baby to eat was [maize porridge]. Did you prepare it?”

3. Continue through each of the items from the 24-hour recall, using a new sheet for each food. You may need to modify the questions based on the specific items and the age of the baby, so ask the questions in a way that is appropriate, encouraging the mother to describe her ideas and practices, and following up on statements to ask for more clarification and opinion. It is important to get as much information as possible, but not to do so in a rigid manner.

Part 2. Other Foods and Experience/reactions with additions to foods

1. When you have completed the questions about the foods on the 24-hour recall, ask if there are other foods the infant gets regularly that you haven’t yet discussed, and write down the names of these foods on the CR Module 3 Recording Form Supplement Sheet.

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Then ask if there is anything different about the way these foods are prepared and fed compared to the foods you’ve already discussed.

2. Now you should introduce the topic of adding something to a food after it has been prepared. For example you can say: “With foods for adults, people often add something to a dish after it has been cooked. For example, sometimes we have condiments at the table, which people can sprinkle on or stir into their food. When you think about the foods that you give to your IYC can you think of any examples or times when you put something on top of a dish or stir something into it after it has been prepared?”

If you receive an affirmative response, probe for details.

If the respondent says she has never done this, ask her whether she can think of any examples of something one might stir in to a baby’s food.

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Caregiver Respondent Module 4

Part 1. Guided discussion about perceptions of value dimensions

Background.

The cultural (ideational) component of the cultural-ecological framework, which provides the theoretical foundation for this FES, is an essential aspect of the study. This module is particularly aimed at obtaining data on how women perceive the characteristics of foods from the perspective of basic value dimensions. The objective is to understand how caregivers view specific IYC foods in relation to their basic cultural values.

There are many value dimensions that one could explore in relation to infant feeding, but in the interests of efficiency and practicality, it is necessary to limit the study to a few key dimensions. Based on anthropological studies in many societies, as well as observations by researchers, we have pre-selected three dimensions related to food in general (not just IYC food) and one IYC-specific dimension to use for this module. The three general dimensions are “healthiness,” “ cost,” and “convenience.” The child-specific dimension is “child acceptance” (of a food.).

The “healthiness” dimension implies that: (a) people value “healthfulness” as a property of foods, and (b) some foods are seen as healthier than others, while some may even be viewed as unhealthy.

The “cost” dimension implies that: (a) foods are not free, (b) that the cost of foods is a concern for most people in most cultures, and (c) that foods differ in the amount they cost, with some foods being viewed as cheap, followed by a range to expensive or costly.

The “convenience” dimension is a general term that may include several different aspects. For some people a convenient food is one that does not require lighting a stove or fire; for some convenience means that it can be purchased close to home; for some convenience may mean a food that doesn’t take a lot of time to prepare; for some convenience means that it can be prepared infrequently and stored for later use. Selecting convenience as a value dimension implies that: (a) people perceive one or more aspects of this general concept as relevant for their perceptions about foods, and (b) that foods differ in their level of convenience.

The “child acceptance” dimension implies that: (a) infants and young children are active participants in the feeding process; (b) that caregivers are aware of the fact that children do not generally passively accept all foods; (c) that children differ in their level of acceptance of foods; and (d) that some foods are more likely to be accepted than others.

During the course of your key informant interviews you may decide that other value dimensions are important in the cultural setting in which you are working. For example, in a culture where three generation families are common, and where the caregiver’s

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mother-in-law has a strong role in IYC feeding and care, the” opinion of others” may be an important issue. The value dimension could be phrased as “approved by other household members.” The implication is that some foods will be perceived as highly approved (e.g. by the mother-in-law), while some foods may be seen as not meeting the mother-in-law’s approval. If you feel this is an important element in the management of IYC feeding, then you may want to add it to the rating task.

It is essential to remember that this exercise measures caregivers’ perceptions. By definition, there are no right or wrong answers. For example, some people may perceive a food to be very unhealthy, although from the perspective of nutritional sciences it would be classified as a nutrient-rich food.

Procedures

1. The first step in Part 1 of this exercise is to be sure that the caregiver understands the meaning of the dimensions. As part of the preparation for interviewing caregiver-respondents, you will have created cards depicting the value dimensions, as well as cards for the individual foods you are going to ask caregivers to rate. (See section on “preparing for the caregiver-respondent interviews).

2. Take out the value dimension cards and lay them in front of the caregiver. Start with the first dimension, eg. “Healthiness,” and explain what the picture (and label) mean. Be sure to ask a question that permits you to know whether she understands the concept. For example, you can ask: “When you think about the healthiness of foods, what are some of the things that make a food healthy?”

3. Write down the caregiver’s comments on the CR Module 4. Part 1. Recording Form.

4. Continue with the other value dimensions, writing in her comments on each dimension.

Part 2. The food rating exercise

Background

The underling values that affect what caregivers feed their IYC are applied to specific foods, and the purpose of the rating exercise is to understand how caregivers view individual IYC foods, including how they see the relative advantages and disadvantages of specific foods in relation to each other.

This part of the module uses a cognitive mapping “rating “ method.

Procedures.

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1. The basic rating technique for this module is described in the Methods section of the manual. Take a set of CR Module 4 recording forms and write in the dimensions, one on each page. Take out the board with the slots and put it on a flat surface.

2. Start the exercise with the caregiver by showing her all of the food cards. Make sure she understands what each picture is supposed to depict.

3. Take the first dimension card (“healthiness “) and lay it on the surface, above the board. Next place the card with the plus sign at one end of the board and the card with the minus sign at the other. (You can also use a happy face and a sad face if that seems better.)

4. Give the food cards to the caregiver, and ask her to place one of them on the slot that best describes her rating. You can say, “If you think this is a very healthy food for babies, put it here.” indicating the slot at the positive end of the board. “If you think it is not healthy, put it here,” indicating the far negative side. “If you think it is somewhere in between, put it in one of the other slots.

5. Ask her to place the rest of the cards on the board. It is important to assure the caregiver at this point that there are no right or wrong answers and that she can change her mind about placement once she has all of them laid out. Record any comments she makes while she is doing the exercise.

6. When she has finished placing all the cards, record her ratings on the recording form. This can be done very quickly if you have used letters to designate the food cards. Be sure to record any comments she makes during the exercise.

7. Shuffle the cards, place a dimension above the board and repeat the procedure for all of the dimensions.

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Caregiver Respondent Module 5

Factors that influence what you feed your IYC

Background. This exercise is an extension of the preceding rating exercise. It is aimed at finding out the caregivers’ views about the relative importance of the different dimensions she used to rate the foods. Here the emphasis is on the dimensions rather than on the foods.

In addition to the three primary dimensions, and the child acceptance dimension, which were used in the previous exercise, in this module we introduce some refinements by subdividing the convenience dimension into several components. Instead of rating “convenience” the caregiver is asked to rate three separate components - “easy to purchase,” “easy to prepare “ and “easy to feed.” You will have cards for these, which you made as part of the preparation for the caregiver-respondents interviews.

This part of the module uses a cognitive mapping “rating “ method.

Procedures

1. Because you have new cards, as well as those you used in the previous exercise, begin this exercise by showing the caregiver the new cards and explaining what they refer to.

2. Select and shuffle all the dimension cards and lay them out in front of the caregiver.

3. You can introduce the task by saying something like “All of these are things you might have to consider then you decide what to buy for your child or what to feed him/her. Probably some of these are more important to you than others. Could you put each of these cards on to the slot that shows how important they are for you. If you think a reason is very important, put it here (indicating high end) or if it isn’t very important, but it here (indicating low end). You can also put it in between. If all of them are the same, you can put them all of them on the same place.

4. Record the ratings on the CR Module 5 Recording Form.

5. Be sure to write down the caregiver’s comments and encourage her to talk about her rating choices.

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Caregiver-Respondent Module 6

Perceptions about micronutrient supplements and fortification of infant foods

Background

For purposes of assessing the potential of a new product that is intended to increase IYC nutrient intake, it is essential to know about caregivers’ understandings and perceptions about “vitamins” and other supplements. The word “vitamins” is put into quotation marks to indicate that we are using it as an emic, not an etic, term because we are interested in how caregivers perceive micronutrient supplements. It is probable that the concept they will be most familiar with is “vitamins,” and therefore the investigation of their perceptions should begin by first exploring their views about this concept. This module is intended to provide insights into caregivers’ familiarity with and interpretations of micronutrient supplements as well as micronutrient fortification of IYC foods. It uses the “open-ended questions with guided discussion” method.

Procedures

1. Start with a clean CR Module 6 recording form.

2. You can introduce the topic by saying “Next I would like to ask your views about vitamins and other things that are sometimes given to babies and young children to help their nutrition. Please remember that I am not testing you to see what you know; I would just like to know your opinions. And if you don’t have any opinions or experiences with them, that is just fine too.”

3. The open-ended questions in this module are also on the recording form, so that once you are fully familiar with them, you can use the form to structure your interview with this module. But please pay close attention to the probing questions that need to be explored after the respondent’s initial statements in response to a question. The order in which the questions appear is a suggested sequence, and you should feel free to deviate from this if the conversation moves in other directions. However it is important to cover all of the issues before you go on to the next module.

Questions related to micronutrients

1. “More and more nowadays it seems that people are talking about vitamins. Have you heard this word before? “

2. “What are vitamins and what do they do?”

3. “Has anyone talked to you about giving your child vitamins? “If her answer is no, ask whether she has ever thought about giving vitamins even though no one has ever talked to her about it.

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4. Have you ever given your child vitamins?

Follow-up probes for a positive answer:

a) In what form did you/do you give them? (liquid, crushed pills, micronutrient packages, Sprinkles, LNS, etc.)

b) What was your experience with giving them that way? Did you have any problems?

c) Do you plan to continue giving them?

5. Why did you decide to give your baby vitamins? (Or, if appropriate, Why did you decide not to give your baby vitamins?)

Important: If the mother’s only referent for “vitamins” seems to be syrup or tablets you need to confirm that this is the case and then explore her reactions to the idea of other forms of supplements. If she already knows about these you will have discovered that and discussed her reactions and perceptions in connection with the preceding questions. If the mother does not mention other forms of supplements, ask the next question.

6. “You’ve told me about giving your baby vitamins in a syrup (or crushed tablet). Are there any other ways that babies can get vitamins? Can you tell me more about that?

If she answers only by discussing vitamins in food or breastmilk ask her directly whether she has heard about other forms of supplements. If she mentions other forms of supplements, probe to find out how she has learned about them; what they consist of, etc.

For all respondents ask the following questions:

7. Have you heard that some foods you can buy in the store have extra vitamins added to them?

If yes, probe to find out what foods, whether she has ever purchased them or thought about purchasing them.

8. The reason it is important to ask the next question is that the caregiver may have heard about nutrient supplements but she does not think of them as “vitamins.”

Finally I’d like to ask if there is any thing else besides food and vitamins, that mothers can give their children to help them have good nutrition?

Probe to find out what she is referring to and what she knows about them. But note, also that if the caregiver says no, she may ask whether you know of something. Be prepared to answer this question. For example you might say that

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you have heard that in some places there are packets or spreads or other things that help a child’s nutrition, but you don’t know if they are available here.

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Caregiver Respondent Module 7

Estimated Weekly Food Expenditures

Background

The purpose of this module is to obtain data on what households spend on food for their IYC, as well as an estimate of what they spend, in total, for all their household food. This is important information for several reasons: (1) It provides a basis for estimating the range in spending for infant foods by low income households in the community/region; (2) It permits an estimate of the proportion of household food expenditure that goes for the IYC.; (3) Along with the household demographic information it permits you to estimate how much is spent, per capita, on food. This, in turn, provides a basis for comparing the situation in the research community with household economic behavior in similar types of communities around the world; and (4) Together with the information on total household income, it permits an estimate of amount of income spent on food, which, like the previous point, provides a basis for broader comparisons.

Some caregivers will know very well the amounts they spend on food and will be able to answer your questions easily. For others, this module will be more difficult. Estimating expenditures for foods that are made or purchased exclusively for the IYC should be relatively easier for the caregiver and should be the focus of your questioning. Try to get as good information as you can on this topic, but if the caregiver seems to be struggling to answer your questions or is reluctant to share the information, do not push her too hard. It is better to have missing information than to destroy the rapport you have developed.

This module also is an opportunity to ask about the purchase of supplements.

Procedures

1. In preparation for asking the questions take a clean Module 7 Food Expenditure Recording Form, go back to the filled out Module 2 Form, and write in the names of the special IYC foods (not family foods) the caregiver reported in the 24 hour recall. Write in the other foods she mentioned that she sometimes gives. If she gives a supplement, write that in as well.

2. You can introduce this module by saying: “Now that we’ve talked about the foods that you give your baby, I’d like to learn more about the costs of food for him/her and for your family. “First, Can you tell me about how much money you spend each week on food for the whole family?”

“Does that include the money that you (and your husband/ partner if appropriate) (your

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children, if appropriate) spend to buy food when you/they are away from the house? If the answer is no, ask “Do you know about how much money you and other members of the family spend for food away from home?

3. Record the answers on the CR Module 7 Food Expenditure Recording Form

4. Next I’d like to know about the costs of foods that you buy or make especially for your baby/child. You mentioned that yesterday you gave him/her ________ (first food). Can you tell me how much it cost to buy a (box, packet, bowl (if ready-to-eat, eg from kiosk) of ____________?

How long does (packet, can, etc.) this usually last?

If less than a week, ask: How many times a week do you buy ________

5) Continue with the other IYC foods that were given yesterday.

6. Next ask about foods that do not appear on the24 hour recall, but which the caregiver said she sometimes gives her baby. You can say: “You also told me about other foods you buy for your baby that you didn’t give him yesterday. You said you sometimes give ___________, ________________, _________

“How much does it cost for (first food)” Continue through the list.

7. Inquiring about supplements. If the caregiver has already reported giving a supplement, you can say “You mentioned earlier that you give your child ______ (name of supplement or description of what she reported) Can you tell me how much this costs?

About how long does it last?

Be sure to note if the supplement is free and is obtained from a social agency or other source.

8. If the caregiver did not report giving any supplements, you can confirm that she doesn’t by asking “Apart from the foods we have just discussed, is there anything else you buy to give your child for his nutrition or health?”

Record her answer on the Module 7 recording form.

Note that there are 2 pages for this form. Use additional pages, if needed.

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Caregiver-Respondent Module 8 Food and feeding-related problems/challenges experienced by the caregiver

Background. The purpose of this module is to obtain information about the personal experiences of the caregiver-respondent concerning food and feeding-related problems. It complements the information that was obtained from the key informants. It starts with an open-ended question about what food and feeding problems, if any, the caregiver has experienced with her child. Guiding questions are used to determine what her approach is (was) to dealing with the problem, what social support or advice she might have received, and whether cost issues are (have been) involved in her management of food and feeding problems.

This module uses the “open-ended questions with guided discussion” method.

Procedures

1. You can introduce the topic by saying:

“Finally, the last topic I would like to discuss with you is the matter of problems or challenges you may have experienced in feeding your child. Many mothers have some challenges when it comes to food and feeding. Have you had any problems or worries about this?

Listen carefully to what the respondent says to see whether she includes information on how she deals with the problem, types of social support and costs (if appropriate). If any of these are missing from her discussion, you can probe for these using guided questions.

Below are some hypothetical examples:

i) “You said that your child is a poor eater and rejects many different foods. Is there anything you do to help this problem? Is there anyone who can help you with this type of problem?

ii) “You said that you sometimes have problems buying food for your infant. Can you tell me more about that? What kinds of things do you when you have this problem ? Is there any place where you can get help?”

iii) “You mentioned that your child is often sick and this affects his/her eating. Can you tell me more about that? What kinds of things do you do when this happens ? Is there any place to go or anyone to help with this problem?

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iv) “You said that sometimes you have so much work it is hard for you to feed your child. Why is this a problem? What can a mother do about this? Is there anything you do when you are very busy to make it easier?

This discussion should be very open-ended, following leads and probing for further information and perceptions.

Record the caregiver’s comments on the CR Module 8 Recording Form, using a separate sheet for each issue.

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