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 I. INTERVIEW WITH CAREGIVER KEY INFORMANTS

CKI Module 1: Foods for Infants and Young Children

CKI Module 2: Food Preparation and Feeding Practices

CKI Module 3: Sources of Food Acquisition and Food Expenditures

CKI Module 4: Types of problems faced by parents of infants and young children

CKI Module 5: Food and Nutrition Problems of Infants and Young Children

CKI Module 6: Health and Food Perceptions

CKI Module 7: Perceptions about micronutrient supplements and fortification of infant foods

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Key Informant Module 1

Foods for Infants and Young Children

Background

This module uses the “free listing” method. You will find a general discussion about free listing in Part II in the section on research methods. The specific purpose of this module is to generate the lists of foods that are given to infants at different stages of complementary feeding. This information will be used for several purposes in the rest of the study, including deciding what foods you will use for the rating exercises with mother-respondents.

Over the 18-month period from about six months, when complementary foods are first introduced to infants to 24 months, when most children are eating family foods, there are many changes in what kinds of foods are given. Therefore, it is important to ask about foods for specific age groups. Based on previous research on complementary feeding, we have divided this period into four different age groups: (a) 6-8 months; (b) 9-12 months); (c) 13-18 months; and (d) 19-24 months. How to obtain information from your key informants about teach of these different age groups is described below at the beginning of the procedures section.

Procedures

All of your key informants will have an IYC because that was a criteria for selecting them. With 8 key informants you should have all of the 4 age groups represented, with 2 in each age group. However, relying on only 2 women for an age group to give you a list of the foods for that age group is not a good idea because this is such a small number. Therefore, you should start by asking your respondent first about the age group of children who are the same age as her own IYC, and then ask “backward in time” and “forward in time” for the other age groups. For example, for the two women with children 6-8 months of age you will start with this age group and then ask them about the older age groups, sequentially. For the 2 women whose children are already 19-24 months, you start with this age group and ask “backward.”

You will see, below, that the way you phrase the request for a list needs to be modified, depending on the age of the respondent’s child. If the child is very young, you use the present tense when asking about young infants, whereas you will have to put that suggestion in the past tense if the child is older, and vice versa. If the child is very young you will use the future tense for 3 age groups, asking about what she is likely to give and what she knows about what children of these ages are given. In any case the goal is to get as large a list as possible. Later you will select which foods to focus on.

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Be sure to get as complete a list as possible by asking the respondent whether there are any other foods she can think of before going on to the next age group.

Questions

(a) For infants 6-8 months of age

1. “ To begin my questions about how babies are fed, I would like to know about the kinds of foods that babies are given when they are first starting to eat something in addition to breastmilk, babies of about 6-8 months. As you think about that you could start by listing the foods that you give (gave) your own baby.

2. Anything else?

3. Are there any foods you don’t give your child, but some people give to their babies when they are first starting to eat?

(b) For infants 9-12 months:

1. When you think about children who are about 9-12 months of age, what kinds of foods are they given to eat? ( You can start with your own child…)

2. Anything else?

3. Are there any foods you don’t give (didn’t give) your child, but some people give to their babies when they are 9-12 months?

( c) For infants 13-18 months:

1. Let’s talk now about children 13-18 months of age. What kinds of foods are given to children of this age.? As you think about that you could start by listing the foods you give (gave, are likely to give) your own child.

2. Anything else?

3. Are there any foods you don’t give your child, but some people give their children when they are 12-18 months?

(d) For infants 19-24 months:

1. Please tell me about the kinds of foods that are given to young children over a year and a half, and up to two years of age. You don’t have to tell me about all the regular foods that are made for everyone in the family. I would just like to know about any foods

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that are made specially for young children or family foods that are prepared differently before they are fed to young children. Do you think of any foods like that? You could start by thinking about how you feed (will feed) your own child.

2. Anything else?

3. .Are there any foods you don’t give or prepare for your child, but some people give their children when they are 19-24 months?

Use the age-appropriate Key Informant Module 1 Free Listing data-recording forms to write down the information the respondent gives you. Put the answers down in the sequence she uses. Be sure to note any comments she makes as she gives you her lists.

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Key Informant Module 2

Food Preparation and Feeding Practices

Background

The purpose of this module is to generate a picture of caregiver behaviors in relation to food preparation and feeding practices. It uses open-end questions about specific food items to guide a discussion to obtain information on the following issues for each of the items: (1) Who prepares the food item? (2) How is it usually prepared? (3) Is a single portion prepared (or purchased) to be fed to the infant immediately, or is extra made and stored to be given later? If stored, in what kind of vessel? (4) Who feeds the baby this item? (5) How is the food given (e.g. spoon, bottle, mother’s hand, pre-chewed by mother, given to child to hold by himself/herself.) (6) Is the item prepared specially for the child or is it made (or purchased) for the whole family? If for the family, is it modified for the infant (e.g., thinned out, less spicy)?

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

Procedures

Applying this module requires making some quick decisions, after you finish the Free Listing exercise, about which items to focus on in the guided discussion. This will be particularly challenging in the first few interviews because as the key informant interviews accumulate you will have a progressively better picture idea about which specific foods are the most essential to know about from the perspective of assessing the potential of the new or modified products GAIN is concerned with. There will be commonalities in the responses of informants, with many of them listing the same items. In making decisions about which foods to ask about keep in mind that your goal in this module is to find out more about the primary foods that families are using to feed their IYC, and these are likely to be the ones that are commonly mentioned.

Start with the list of foods for infants 6-8 months. This will probably be a short list. You may want to ask about all the items the respondent has mentioned. Use the Module 2 data-recording sheets. Start with a blank sheet and write the first food you will ask about on this sheet. Continue with the next food on a new sheet. Continue with other foods from the 6-8 month free list that you are interested in.

Next look at the responses for the 9-12 month olds. Remember that your goal is to learn about the foods that are most important in relation to the new product(s) of concern. Which foods are most important will depend on the type of product GAIN is assessing. For example, if the new product is a gruel or porridge, it is important to learn more about all of the cereals/gruels that are given to IYC. Some of these may not be given before 9 months, so be sure to ask about these with the Module 2 questions.

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Continue with this procedure until you have asked about all of the food items you think are relevant. Remember to use a new sheet for each item, and be sure to record the comments that are made about the items in the course of discussion.

Make enough blank copies of the data-recording form to cover all the food items you are going to ask about in the interview.

Module 2 Questions

You can introduce the discussion by explaining: “I’d like to learn more about the foods that babies and small children are fed. This will help us understand what families do to prepare foods and how they feed them. To start I would like to ask you about _________ (first food)

Here are the questions to ask about each food. The questions are also on the data-recording forms to help you keep a good flow in the discussion.

1) Who prepares (the food item)? Probe: Does anyone else ever prepare it?

(2) How is it usually prepared? Probe for cooking fuel, cooking time, whether boiled water is used. If it is purchased ready-made, ask what the informant thinks the cooking procedures are.

(3) Is a single portion prepared (or purchased), which is fed to the infant immediately or is extra made and stored to be given later? If stored, in what kind of container is it kept? Is it refrigerated?

(4) How is the food given to the baby? (eg. spoon, bottle, mother’s hand, pre-chewed by mother, given to child to hold by himself/herself.)

(5) Who feeds the baby this item?(Ask specifically about what happens when the mother is away (e.g. working) or the baby is in a crèche)

(6) Does anyone else in the family eat this food or is it made (or purchased) just for the child? If for the family, is it modified for the infant (eg, thinned out, less spicy)?

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Key Informant Module 3

Sources of Food Acquisition and Food Expenditures

Background

The purpose of this module is to obtain data on where households buy the foods they feed their infants and how much they spend for these foods. It uses two methods: open-ended questions with guided discussion (Part 1), and a geographic mapping technique (Part 2). Geographic mapping is described in the methods section in Part II.

Procedures

Part 1. Where caregivers obtain their foods (using open-ended questions)

Before you start this discussion, quickly review your notes from Module 2. You will see that you probably talked about several different kinds of foods. Some of the foods are made especially for infants and are completely prepared at home from ingredients. Other home-prepared foods are made for the whole family. Some foods for IYC are commercial foods that are partially prepared, but need some additional preparation before they can be given to the infant, For example, infant cereals both instant and non-instant, fall into the category. Finally there are foods that are purchased ready-to-feed without any preparation. These are often foods from street vendors or food items that need no preparation, such as fruit-flavored yogurt. It is likely that these different kinds of foods will be obtained from different food sources. Therefore, the discussion with the key informants will proceed more smoothly if you organize your questions in relation to these different types of foods. It might be easiest to start with the ready-to eat-foods. For example, if caregivers are purchasing infant gruels or porridges from street vendors or neighborhood kiosks, you could start with these. Some of these ready-to-eat foods might also be eaten by the whole family, and you should note this on the recording form.

When you have discussed the ready-to-eat foods, go on to ask about the foods that are partially prepared. Then you can ask about the foods that are totally home prepared, beginning with the foods that are specially made for infants. The home-prepared foods may involve ingredients that are obtained from different sources, so this will be a little more complicated to discuss.

Use the Key Informant Module 3 data-recording form to record the answers.

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Questions

1. Opening the discussion about sources of food acquisition. You can use the following:

I’d like to learn more about where people buy the different kinds of foods and ingredients you have just told me about, and I would also like to know about how much they cost. Let’s start with (first ready-to-eat food.) You could begin by telling me about where you buy this food.

Record the response on a Key Informant Module 3 Data-recording form.

Probe for details.

Very important: if the key informant gives you more than one source ask if there are any differences between source 1 and source 2, and if one is preferred over the other and why that is.

When you have finished discussing where the respondent buys this food, you can then say:

“You’ve told me about where you buy (x - food). Do most people buy (food) from (give sources, e.g. street vendors). Are there any other places where people buy (x- food)?

2. Asking about the cost of foods.

You can shift the discussion to costs by asking:

“Okay, now that you’ve told me where you buy x- (food) can you tell me how much you usually pay when you buy (x- food) ?

Make sure you have the unit of purchase your respondent is using and a description of package size, etc.

Be sure to clarify whether this is a purchase just for the infant or whether is eaten by other family members.

Also, remember to probe about whether costs for this food vary from one acquisition source to another.

After you have the cost information, ask:

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

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3. Continuing with the food acquisition and cost discussion: start with a new data-recording form and ask about the next food. Follow the two-stage procedure you use for the first food: sources of acquisition, followed by cost.

Important: when you are discussing information on home-prepared foods, be sure to ask specifically about different ingredients. You may find that the same food is prepared with different ingredients, and that these may be obtained from different sources. For example, in a study in Accra, the investigators found that home-fortified infant cereals were made from a variety of different ingredients. Sometimes these ingredients were obtained from the local child welfare clinics, and sometimes they were purchased in food stores. Where they were obtained made a difference in what people had to pay, but it was more difficult to get them from the child welfare clinics.

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Procedures

Part 2 Geographic and social mapping

Background. The purpose of this exercise is to identify the physical environments in which food acquisition occurs. This is important information to connect current practices with future planning around marketing. Four types of food acquisition locations should be determined in this exercise:

1. Purchase of ingredients to prepare food for IYC

2. Purchase of ingredients to prepare food for family

3. Purchase of ready-made foods for infants (specify foods)

4 . Purchase of ready-made foods for family (specify foods)

Procedures

1. In preparation for the caregiver key informant interviews, be sure to include the physical materials you will need for this exercise: large sheets of paper and colored pencils.

2. Spread out a piece of paper in such a way that the respondent can easily place markings on the paper.

3. Assure the respondent that the results do not have to be pretty or accurate in dimensions and distances.

4. Ask the respondent to draw, free hand, some main features of their neighborhood, eg. the main road(s), a market areas, areas of stores.

(Note:  People will often resist “taking hold of the pencil” and will ask the investigator to do the drawing. If the respondent strongly resists, you can start the drawing for them. )

 5. After a general map has been established, ask the respondent to indicate where she (or other family members) go to purchase each of the categories of food above. Ask questions about each of the places so that you get full details. Then discuss the characteristics and qualities of the various locations to get further information about why these choices are made and the benefits and downsides of the various options.

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Key Informant Module 4

Types of problems faced by parents of infants and young children

Background

This module is the first of three related modules to gather data about how food and feeding decisions and behaviors fit within the larger context of taking care of infants and young children. It is important to remember a basic theoretical point, which is that for mothers and other family members, feeding the IYC is just one of several critical behaviors they have to carry out to keep their child alive and healthy. From the perspective of the nutritionist or the marketer of a food product food and feeding is the central, even the only, object of concern, but this cannot be the case for the adult(s) who have responsibility for the baby. This set of three modules is intended to provide insights into how food and feeding fits within this larger set of responsibilities. Understanding that is essential because it is the caregiver’s larger “framework” that ultimately influences her food and feeding decisions and behaviors.

Purpose

The purpose of this specific exercise is to generate a list of problems that caregivers face. By asking about “problems” in general, without specifying food and nutrition problems, you get a better idea about the relative importance of food and feeding problems in relation to the other problems households have to cope with.

This module uses the free listing method followed by additional probing, as necessary, to obtain an overview of the interviewee’s perceptions about the issues she is discussing.

Procedures

Introduce the topic by starting with a general statement, such as the following:

“Most people are very happy when they have a new child. Children bring so many blessings into our lives. But no matter how much we want a new baby, it is always the case that they take a lot of care. I would like to ask you now about problems that families have when they have an infant or young child. Can you list for me the kinds of problems that mothers often have when they have an infant or young child?”

This is a suggested opening statement, which you can modify as you see is appropriate. The statement should direct the key informant’s attention to the area you want to discuss and get them to generate a list. At this point you are not probing for details about each problem. You want her to give you a list, so be sure to use a phrase that includes something like “please list for me…”

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If the respondent has difficulty understanding the question you will have to give some guidance, but it is best not to suggest specific infant-related problems, so you can use a related subject. For example, you can say “Well, when it is time for children go to school many families have a problem of money for school fees, or they may have a problem because the child is afraid and doesn’t want to go to school. So, as you think about families with a baby or a young child, what kinds of problems are they likely to encounter?”

Expand the list by asking: “Is there anything else”

Important: record the answers on the Module 4 recording form in the order in which they are given. Remember that the main purpose of this question is to find out how salient or important issues about food and feeding are compared to other issues. Are they among the first problems mentioned or do they appear lower down on the list or at all?

When the respondent cannot think of anything else, review the list to see whether she has mentioned any problems related to food and feeding. If there are no food or feeding-related problems, then prompt by asking specifically about whether families have any problems around food and feeding. Be sure to clearly indicate that these were NOT spontaneously generated and only appeared with a direct question.

The Module 4 Recording Form has places for 8 problems. An informant may give you less or more. In the case of more, just add additional numbers below number 8 on the form. There is space for each number to make a few notes about what she says. If she gives you more information, use the space below the free list numbers to write notes. Be sure to indicate which problem or issue the comments relate to.

As this is a free listing exercise, you don’t need to get detailed information about each item. However, some of the problems may relate to food and nutrition, in which case you ultimately want to get a lot of information. The next module (Module 5) is devoted to expanding your knowledge base about food and nutrition problems. If the respondent starts to provide more detail about the food and nutrition problem, let her finish her thoughts and be sure to write down the details. At the same time you want her to continue to generate her list, so you can say something like: “That is very interesting. I’d like to discuss this more in a few minutes, but first, let’s finish your list.”

This module requires a balance between letting the key informant follow her own pace, letting her say as much as she wants about a specific problem, versus generating her larger list. It is very important that you do not cut her off and that you show an interest in everything she has to say, particularly if it is an interesting or sensitive subject. You shouldn’t probe here about food and nutrition problems unless you think that it will be hard to come back to the topic in the next module. But you should also feel free to probe further about non-food and nutrition problems if you feel they are important to understanding mothers’ behaviors. For example, if your informant talks about conflict between husband and wife, or between mothers and mothers-in-law, you can ask more questions.

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Most important: USE YOUR JUDGMENT ABOUT HOW MUCH TO PROBE.

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Key Informant Module 5

Food and Nutrition Problems of Infants and Young Children

Background

The purpose of this module is to explore the nature of the food and feeding-related problems the key informant has identified in her free listing problem list generated in Module 4. Among the types of information you want to obtain are her perceptions about:

i) Strategies for dealing with the problems ii) Types of social support to help deal with the problemsiii) Costs of dealing with the problems

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

Procedures

Review the problem list on the Module 4 recording form, and make a check mark beside each problem that relates to food and feeding.

You can introduce the discussion by saying:

We have just talked about the different kinds of problems families have when they have a baby or a young child. Some of these problems are about food or about feeding. I would like to ask you more about these food and feeding problems. Let’s start with (first checked item). You said: “_____________________________” Can you tell me more about that?”

Encourage the interviewee to range freely, emphasizing whatever she feels is important. Listen carefully to see whether her comments include ideas about how to overcome the problem (strategies for dealing with it), whether she mentions types of social support in relation to the problem, and whether she brings up issues of cost in relation to the problem. If these specific issues are already covered in her discussion, there is no need to bring them up. However, if they are not, then probe for details relating to these. Below are some hypothetical examples.

Hypothetical examples:

i) “You said that some children (your child) are poor eaters and reject many different kinds of foods. What kinds of things can one do to deal with this problem? Is there anyone who can help you with this type of problem?

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ii) “You said that some families (you) have problems buying food for their infants. Can you tell me more about that? What kinds of things do they (you) do about this problem ? Is there any place where they can get help?”

iii) “You mentioned that some children are sick a lot and this affects their eating. Can you tell me more about that? What kinds of things do they (you) do about this problem ? Is there any place where they can get help?”

iv) “You said that sometimes mothers are so busy they don’t have time to sit down and feed the child. Why is this a problem? What can a mother do about this? Is there anything she can do to get help?”

This discussion should be very open-ended, following leads and probing for further information and perceptions. If nothing related to these themes is mentioned, you can ask probing questions, but only if they are appropriate to the discussion. For example, if a respondent says that the amount of time it takes to feed the infant (solid) food is a problem and she does not mention getting help from other family members, either to feed the baby or to take over some other task when she needs to feed him/her, you can ask specifically about whether she ever does this and/or whether she thinks it is common in the community to ask another family member to do this.

Record the key informant’s comments on the Key Informant Module 5 Recording Form. Use a different sheet for each problem.

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Key Informant Module 6

Health and Food Perceptions

Background. The purpose of this module is to understand women’s views about how food relates to keeping children healthy. This is important for several reasons:

(1) To assess the extent to which nutrition is salient to their goals of having healthy children.

(2) It also provides insights into people’s conceptions about the health aspects of foods.

(3) If they mention growth in their discussion in provides information about how they view child growth as an aspect of health, and how it relates to foods. If they do not mention anything about growth, this is also important because it suggests that they do not see a close connection between food and growth.

(4) This module also provides insights into how caregivers view the relationship of foods to vitamins, and related matters.

This module uses the “free listing” method in Part 1, and “guided discussion” in Part II, based on the results of the free listing.

Part 1. Free listing about keeping children healthy

Background

This part of the module is used to generate the list of things families do to keep their IYC healthy. Its purpose is to enable you to discover where food and feeding fit into the larger picture of keeping children healthy.

Procedures

1. The following question can be asked to initiate the free-listing:

You’ve told me a lot about the kinds of problems that families with young children have, especially problems related to food and to feeding them. Now I’d like to ask you a little about keeping children healthy. Can you tell me about all the things that families can do to keep their children in good health?

Anything else?

Note: the respondent is likely to start with food-related items because the previous discussion has oriented her to foods and feeding. Record the respondent’s answers in the

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order in which she lists them. If she stops talking and has not mentioned anything about food or vitamins, you will have to ask a direct questions, such as:

“You haven’t mentioned anything about foods or feeding. Are there some things that mothers should do or can do to keep their children healthy that have to do with foods or nutrition? (Do not use specific words about “vitamins” or “tonics,” but wait to see whether the respondent mentions them. If she does not, wait until the end of the guided discussion (see below) to ask about them.

2. Record the answers in the order the respondent lists them on the Key Informant Module 6 Recording form.

Part 2. Guided discussion about the food and feeding items on the free list

1. Scan the free listing and put a mark beside each item that relates to food and nutrition.

2. You can start the discussion by saying: “You’ve mentioned a number of different things that can be done to help children to be healthy. I’d like to ask you more about some of these. Let’s start with “xxx.” (The first item on the free listing related to food, vitamins, etc.) “Can you tell me more about why xxx is important?”

3. Continue through the list until you have discussed all the food and nutrition related items.

4. If the respondent did not mention “vitamins” (or a specific commercial vitamin preparation) now ask her specifically about them.

5. Finally, if the respondent does not mention the idea that foods can be fortified, ask her if she has ever heard about the idea that vitamins and iron can be added to foods. If the answer is positive, explore her understanding of this concept and whether she knows of any foods that have added nutrients (using the appropriate words, phrases).

Record the respondent’ s discussion, using a separate sheet for each of the different items from the free listing.

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Caregiver-Key Informant Module 7

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

You can introduce the topic by saying “I have one more topic to discuss. More and more nowadays it seems that people are talking about vitamins. 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.

1. What have you heard about vitamins?

2. Do you or other mothers you know give vitamins to their IYC?

Follow-up probes for a positive answer:

a) In what form do IYC get vitamins (eg. liquid, crushed pills, micronutrient packages, etc.)

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

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

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Important: If the key informant’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. The following questions are designed to help you do this,

3. “You’ve told me about giving babies 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.

4. 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.

5. 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 key informant says she does not know about anything else, she may ask whether you know of something. Be prepared to answer this question. For example you might say that 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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