Abstract
Background
The impact of the Conditional Cash Transfer Program in Mexico was significant but smaller than expected. Several bottlenecks related to program design and implementation have been identified that may have limited its impact; population and other contextual factors may be equally important to analyze.
Objectives
We aimed to explore how sociocultural context contributes to poor nutrition in Mexico and how it shaped the acceptability, fidelity, and penetration of the fortified food and of education sessions provided by the program.
Methods
We carried out qualitative research studies in the central and southern states in urban, rural, and indigenous settings between 2001 and 2014 with different informants and by using interviews, focus group discussions, and nonparticipatory observation. We explored 4 dimensions of the sociocultural context: objective dimension (e.g., food availability and family organization), social norms and symbolic meaning related to child feeding, literacy and communication with the biomedical culture, and knowledge related to child care generally and child feeding. We generated information about the experience of the beneficiaries with fortified food and education sessions.
Results
Several sociocultural factors, including patriarchal family organization, high availability of nonnutritious food, social norms promoting the consumption of food in liquid form for young children, sharing of food among family members, traditional knowledge, and communication barriers with the biomedical culture, participated in shaping the poor nutrition situation, the inadequate utilization of fortified foods, and the inappropriateness of the education sessions.
Conclusions
Our studies revealed the importance of local context and culture to understand the acceptance, utilization, and impact of a nutrition program and shed light on infant and child feeding practices. This knowledge is critical to strengthen program designs and ensure adequacy with the diversity of cultural and social contexts in which programs are implemented.
Key Words: implementation research, qualitative research, emic, infant and young child feeding practices Conditional Cash Transfer Program culture
Introduction
Mexico, a middle-income and multiethnic country, continues to struggle with high levels of poverty and undernutrition through child stunting, anemia, and micronutrient deficiencies. These problems are mostly concentrated in vulnerable groups, such as the indigenous populations (1, 2, 3,4). Moreover, in recent decades, the prevalence of obesity has increased dramatically, also affecting the groups in which undernutrition persists (3, 4).
Several public programs have been established to tackle hunger and undernutrition (5). Among these, the national Conditional Cash Transfer (CCT) Program was designed and launched in the mid-1990s (6), originally named Progresa, then Oportunidades, and currently Prospera [referred to here for simplicity as Progresa–Oportunidades–Prospera (CCT-POP)]. CCT-POP was designed and operated by a government agency created especially for this purpose (Prospera Social Inclusion Program). Various universities and research institutions were mandated to carry out the evaluations of the program throughout the years, of which many were coordinated and led by the National Institute of Public Health in Mexico. CCT-POP is the main federal social protection program that includes actions to incentivize families to invest in human capital through improved education, health, and nutrition. In 2015, it had >6 million beneficiary families (7). Details on the program are summarized in García-Guerra et al. (8) and Neufeld et al. (9).
Evidence shows that complementary foods used in low-income populations in Mexico are mostly monotonous and staple foods, such as maize, and include very few animal-based products, fruits, or vegetables (10, 11). At the core of the actions tackling malnutrition were fortified food supplements provided to caregivers during pregnancy and lactation (Nutrivida) and to all children aged 4–23 mo (as of 2006, this was modified to 6 mo) and children aged 2–4 y with low weight for age (Nutrisano) (12). Many studies were carried out during a 13-y period to improve the formulation and acceptance (8) and to explore alternatives to these fortified food supplements (13). The supplements were provided to caregivers and children during antenatal and routine child health visits. One of the program's conditionalities was caregivers’ participation in education sessions on health and nutrition topics, which were carried out monthly by primary health care providers. Preparation and use of fortified food supplements was 1 of the 25 topics related to health, nutrition, and hygiene that were discussed (14).
García-Guerra et al. (8) examined some of the many studies related to the cash component and highlighted that the impact of CCT-POP on nutritional outcomes was significant but was smaller than expected on anemia and growth, which may have been attributable to several design and implementation challenges, as noted by others (15).
The inadequate use of Nutrisano for infants and young children (IYC) (16, 17), the weak education sessions, and poor counseling when Nutrisano was provided during routine health visits (18) were some of the challenges documented in the previous studies and were the starting point of our sociocultural studies. We define culture as “a process of continuous production, updating and transformation of symbolic models (in its double meaning of representation and orientation for action) through individual and collective practice, in historically specific and socially structured contexts” (19). Culture shapes child feeding practices through several mechanisms: selection of consumed foods among edible foods, those defined as food (20), construction of meanings around food (21, 22, 23, 24) that can demonstrate status and social distinction (23, 25), and other functions such as care and love (26). The “sociocultural context” involves an intertwining of objective (e.g., place, maternal time, and competing demands on caregivers’ time) and subjective dimensions (e.g., knowledge, values, attitudes, and social practices), both of which have implications for perceived relevance, acceptance, and use of programs and the services/products provided. This article presents a social science approach that aims to understand, from the perspective of CCT-POP beneficiaries, how sociocultural context contributes to poor nutrition in Mexico and how it shapes acceptability, fidelity, penetration of fortified food, and the education sessions provided by the program.
Methods
We conducted several studies exploring sociocultural aspects, and review here those focusing on feeding practices and program utilization to identify limitations in program design. We present 5 studies carried out by the National Institute of Public Health of Mexico in the central and southern states of the country (Chiapas, Oaxaca, Veracruz, Guerrero, Puebla, and Querétaro) between 2001 and 2014 (Table 1). These states were selected because of their high prevalence of stunting in children, their large indigenous populations, and because they have the largest proportion of CCT-POP beneficiaries.
TABLE 1.
Characteristics of qualitative studies reported, carried out in rural, urban, and indigenous settings1
| Study no. | Objective | Topics addressed | Design, population, and methods | Setting | Years | References |
|---|---|---|---|---|---|---|
| 1 | To define and explore the sociocultural factors that could enhance (facilitators) or interfere with (barriers) the adequate consumption of Nutrisano by children aged 6–59 mo, provided as part of the national program CCT-POP | Use and acceptability of Nutrisano among caregivers and children, and the health education sessionsOrganizational, cultural, poverty, and other aspects of context.Caregivers’ knowledge of Nutrisano (its benefits, preparation, source of information, etc.).Based on ecological model, barriers and facilitators to adequate consumption of Nutrisano and, feeding practices. | Cross-sectional, qualitative study.Sampling method: the number of interviews and focus groups was determined by a purposeful sampling of informants. Data collection:
|
Rural and indigenous (2 states) | 2001–2008 | (37, 38) |
| 2 | To generate useful sociocultural information to design a communication strategy to improve the consumption of Nutrisano among children beneficiaries of CCT-POP | Perception of caregivers about infant feeding practices, beliefs, and Nutrisano | Cross-sectional, qualitative study.Sampling method: the number of interviews and focus groups was determined by a purposeful sampling of informants.Data collection:
|
Urban (2 states) | 2005–2009 | — |
| 3 | To generate sociocultural information useful to design a communication for behavioral change strategy to improve the intake of Nutrisano in Mexican indigenous children in the state of Guerrero | Barriers for each promoted behavior in Mixteco zones (indigenous): results from formative researchCaregivers and children's experience with Nutrisano.Problems related to child feeding practices and with the use and adequate consumption of Nutrisano | Cross-sectional, qualitative study.Sampling method: the number of interviews and focus groups was determined by a purposeful sampling of informants.Data collection:
|
Indigenous (1 state) | 2006–2008 | — |
| 4 | To generate sociocultural information useful to design a communication and training plan for the Integrated Strategy for Attention to Nutrition | Child care practices and its transformation among IYC and family organization.Description of IYC feeding practices.Identification of barriers and facilitators of exclusive breastfeeding, complementary feeding, and healthy eating | Cross-sectional, qualitative study.Sampling method: the number of interviews and focus groups was determined by a purposeful sampling of informants.Data collection:
|
Rural, urban, and indigenous (1 state) | 2008–2012 | (39) |
| 5 | To generate sociocultural information useful for validation of interpersonal communication strategy and formative research for the proposed national nutrition strategy | Children: influences of child care and IYC feeding practicesIYC caregivers’ perceptions, motivations, beliefs, and practices related to exclusive breastfeeding, complementary feeding, healthy feeding, handwashing, and use of oral rehydration salts.Barriers and facilitators related to exclusive breastfeeding, complementary feeding, healthy feeding, hand washing, and use of oral rehydration salts. | Cross-sectional, qualitative studySampling method: the number of interviews and focus groups was determined by theoretical saturation of the information.
|
Rural and urban (2 states) | 2013–2016 | — |
CCT-POP, Conditional Cash Transfer—Progresa–Oportunidades–Prospera; IYC, infants and young children.
Women of the community—grandmothers, midwifes, or women with previous experience as volunteers for CCT-POP.
The 5 studies were part of the formative research process (27) and aimed to identify cultural and local constraints and opportunities to improve the use of Nutrisano (studies 1–3) or to design a communication and training plan to strengthen primary health care providers’ counseling abilities and technical knowledge to facilitate caregivers’ adoption of IYC feeding practices in line with WHO's recommended practices (28, 29) (studies 4–5). Most of the results presented here have not been previously published.
Definitions of acceptability, fidelity, penetration, and child feeding
We used 3 constructs from implementation research to approach the utilization of the program: acceptability, fidelity, and penetration (30). Acceptability reflects the favorable or unfavorable opinions and assessments of caregivers with respect to Nutrisano and the nutrition and health education component. Fidelity is defined as the degree to which an intervention/activity is implemented and carried out as intended and, in this case, refers to caregivers’ adherence to Nutrisano preparation and consumption recommendations. Finally, penetration corresponds to caregivers’ incorporation of practices and behaviors promoted by the program.
Child feeding practices and child care were defined as proposed by Pelto et al. (31). The included proposal aimed to answer questions regarding what was provided, by whom, and when. Therefore, in all studies we explored the family dynamic around child feeding; the frequency and scheduling of feeding; and, for studies 4 and 5 (Table 1), the types of food given to the child, in terms of quality/quantity and consistency of the food.
Study design, data collection, and analysis
The 5 studies (Table 1) were based on a common approach to understanding contexts, populations, and their cultures (lifestyles, aspirations, feeding practices, needs, etc.). Drawing on previous literature (32, 33), in all studies we used 3 data collection instruments:
-
1
Interviews with caregivers and health care providers to explore practices, fidelity, and penetration of messages
-
2
Focus groups to identify current and past social norms related to food, feeding practices, experience with the CCT-POP in general and in particular with Nutrisano, and the education sessions
-
3
Nonparticipatory observations to explore context and caregiver–child interaction, both in general and specifically during feeding (31)
Communities for each of the studies were selected by convenience among those with high numbers of children aged <5 y. For all studies, the principal informants included caregivers/mothers of children aged <5 y, health care providers (including physicians, nurses, nutritionists, and health promoters), local female community leaders, grandmothers, and fathers (only study 5). We used purposeful sampling to identify informants based on the specific research questions for each study (34). We identified caregivers from the health center's list of program beneficiaries, seeking diversity among respondents and based on the following inclusion criteria: sex and age of the children and numbers of children, selected from primiparous and multiparous mothers. For health care providers, we similarly sought to include diversity of sex, position, and years of service. Community leaders, grandmothers, and fathers were identified using the snowball technique (35).
All interviews and focus groups were audio recorded, transcribed verbatim, and coded using a combination of pre-established and emerging categories of analysis (36). Observations in homes were recorded using checklists. Data analyses used standard techniques for text analysis and observational data (36). Results were triangulated from different data sources to increase the validity of results and obtain a deeper understanding of the issues related to each study aim.
Because our respondents were program beneficiaries, this raised an additional challenge: the fear of losing their benefits from the program could have influenced their responses. As researchers, we had to emphasize our independence from the program and examine the narratives from individual interviews and focus groups for signs of self-imposed censoring.
Background for the analysis: social science constructs that underpinned our approach
Our approach to formative research was grounded in several fundamental principles drawn from the social sciences: 1) behavior is grounded in people's daily life knowledge about multiple subjects, which guide their actions (40); 2) to understand peoples’ actions, it is essential to obtain their perspectives (referred to as emic perspectives) and not impose the researchers’ perspectives (41); 3) food and feeding practices reflect multiple values and motivations, such as love, markers of status, and social group membership (23, 25). We used the grounded theory as a theoretical/methodological framework (36) to guide analyses exploring these elements.
We identified 4 interconnected processes that shape IYC feeding and utilization of the CCT-POP program (Figure 1). The objective dimensions draw on Mintz's (21) theoretical framework, which highlights the relation between general context (forces that condition availability of food), practices, and the production of meanings around practices. To address this dimension, we began with data on food availability and the origins of food consumed within households, family organization and caregivers’ activities, and maternal time and competing demands on it. We then added 3 more dimensions: 1) caregivers’ literacy and communication with the biomedical culture, as the health component of the CCT-POP is carried out through primary health centers and evidence shows a positive relation between health literacy and health-related outcomes; 2) social norms related to IYC and their symbolic meanings, which are internalized norms guiding actions and behaviors, thus facilitating their functioning (37); and 3) knowledge (both traditional and biomedical), which shapes caregivers’ response to Nutrisano and to the health and nutrition education component of CCT-POP. Media, advertisements, and other sources of information may also influence caregivers’ knowledge.
FIGURE 1.
Framework for the 4 interconnected processes shaping child feeding practices, including pattern of use of Nutrisano and understanding and acceptance of education sessions.
Ethical considerations
The Ethics and Research Commissions of the National Institute of Public Health approved all studies prior to their beginning. Participation was voluntary, and all potential participants were provided full details of the objectives, methods, risks, and benefits of the study. Participants gave their oral consent.
Results
The general context is key to understanding child feeding practices and caregivers’ use of the nutrition and health components of CCT-POP. We therefore first present an overview of the general context of the community with CCT-POP and then address the limited utilization of Nutrisano and the nutrition and health education component of CCT-POP through our 3 core components (acceptability, fidelity, and penetration).
In each section, results are presented as a synthesis, reflecting the findings consolidated across all data collection methods, and as informed by the perspectives from caregivers, other key family members, and health care providers.
Sociocultural context of the poor community with CCT-POP
We identified in the sociocultural context 4 processes that shaped the child feeding practices and the use of the program by the beneficiaries (Table 2): the objective dimension, with a patriarchal family organization, the important role of mothers-in-law in child feeding, and a poverty context with very little access to healthy food; social norms related to child care and feeding practices, sometimes in contradiction with WHO recommendations (28, 29); and a cultural gap between communities and physicians (literacy and knowledge) with regard to health and nutrition.
TABLE 2.
Principal factors that explain IYC practices in the 5 studies characterized by child feeding practices distant from WHO recommended feeding practices and a low CCT-POP utilization1
| Dimensions explored | Principal results |
|---|---|
| Objective dimension: poverty context and food insecurity with little access to variety of healthy food | In the southern states, communities are based on a patriarchal organization (studies 1 and 3–5), and mothers-in-law in rural and some urban communities are highly influential regarding how IYC should be fed and cared for (all studies).Mothers are busy all the time and have many household tasks (studies 1–5).Obesogenic context (high availability of high-energy and low-nutrient foods in local stores + advertisements in public places) (studies 2–5).High availability of baby bottles and formula (studies 1–5). |
| Social norms and symbolic meaning | Food is shared among all family members.Food in liquid form: most common way to prepare food in indigenous and rural food (pozol and broths).The valorization of high-energy and low-nutrient foods, or formula milk, is associated with social status.Children have control over their feeding and decide what, when, and how much to eat.Being a “good mother” is never to force the children.Indigenous and rural caregivers do not conceptualize the existence of specific food adapted to children's needs (studies 1–3).Breastfeeding is less accepted once children grow older and their teeth appear (i.e., after the first 4–6 mo).Young caregivers (urban communities) do not wish to breastfeed for aesthetic reasons (study 5).It is “bad” to breastfeed for a long time (for the baby and for the mother) (studies 1–5). |
| Literacy and communication with the biomedical culture | Language barriers for indigenous women (studies 1, 3, and 4).Primary care providers and specially physician use of technical words and usually ignore local culture (all studies).Cultural gap between local culture and biomedical approach regarding causes of illness and child care practices (studies 1–3) with evil conditions of illness such as “mal de ojo” and “malos aire.”Caregivers do not necessarily see any connection between illness and food consumption (studies 1–3). Inadequate food, unhygienic conditions for food preparation, or pathogens were not commonly identified as potential causes of illness.The instructions of the mothers-in-law to mothers about how to feed children can be very different from those provided by primary care providers (studies 1 and 3–5). |
| Knowledge related to children's care and alimentation | “Empacho” (studies 1 and 3–4): a traditional cause of stomach aches in children aged <2 y.Leaf tea is a good treatment for stomachaches, even for children aged <6 mo.Introducing small pieces of food (probadita) at early ages (<6 mo) to get the infant's stomach used to it (studies 1–5).Perceptions of the population that the foods advertised on television are hygienic and healthy (studies 2 and 4–5).After 3 or 4 mo, their milk is not sufficient to feed their infants (studies 4–5).Continued breast milk intake after age 6 mo can lead to weaning problems (studies 4–5).When they get sick, mothers think that they should not breastfeed because they might infect the infants (studies 4–5).Continuing breastfeeding after 1 y “empties” the mother of her energy (studies 4–5). |
1 IYC, infants and young children.
In Mexico, traditional knowledge related to child care is transmitted by caregivers or mothers-in-law and/or through other community channels. In the context of CCT-POP, primary health care providers can transmit biomedical knowledge during health and nutrition education sessions or counseling during routine care visits. Mothers-in-law usually promote traditional practices, which are often very different from the recommendations presented to caregivers in health centers. For example, providing liquid foods and beverages (e.g., tea) and introducing small pieces of food (probaditas) at early ages “to get the infant's stomach used to it” were common practices that mothers-in-law and grandmothers promoted and defended (studies 1–5). Family organization was a barrier for compliance with recommendations from primary health care providers (results from studies 1 and 3–5). In addition, throughout the years, we observed increasing availability of high-energy and low-nutrient foods in local stores in almost every setting and advertisements in public places (e.g., posters) (studies 2–5). Primary health care providers also observed an increased intake of such foods among IYC and in all types of communities.
The cultural gap between communities and physicians is another characteristic of these communities. Many physicians were undergraduate practitioners with temporary positions for their social service. They usually came from urban areas and/or not from the states in which they were working; therefore, they were not familiar with local culture behaviors, social norms, and feeding practices. This gap is also related to differences in the understanding of illness and child care practices (studies 1–3). Empacho (studies 1 and 3–4) is an example from traditional knowledge used to explain the cause of stomachache in children aged <2 y, in which it is believed that stomachs of IYC can only digest foods in liquid form. Solid and semisolid foods are thought to stick in the stomachs of IYC and cause empacho.
IYC practices
As presented in Table 3, infant and young child feeding practices are not aligned with WHO recommendations (28, 29). These local practices were supported by a set of beliefs and knowledge. For example, contrary to the WHO recommendation of exclusive breastfeeding up to age 6 mo, liquids were introduced early, including grandmothers’ remedies (e.g., fresh leaf tea) to relieve infants with colic.
TABLE 3.
Description of IYC feeding practices1
| Practices | Results |
|---|---|
| Family food practices | Family and child feeding practices are built in the context of poverty.Caregivers strive to feed the whole family within economic constraints by the purchase of inexpensive filling foods (pasta, rice, beans, etc.) and/or from subsistence production (e.g., beans, corn, and zucchini).Few high-protein foods are included in family meals, and the diets of IYC are mostly monotonous, based on staple foods. |
| IYC common feeding practices | General:
|
0–6 mo:
|
|
6–23 mo:
|
|
24–29 mo:
|
1 IYC, infants and young children.
Exclusive breastfeeding is the social norm during the first 3–4 mo of an infant's life. However, the practice of breastfeeding was more common in rural and indigenous areas than in urban areas, and it was less common among younger caregivers, who believed breastfeeding causes breasts to sag or fall. Caregivers also explained that the decision to breastfeed does not depend on the caregiver but, rather, mainly on infants and their acceptance of breastfeeding, interpreted as their desire to continue or not.
Several social norms underpin practices related to breastfeeding. For example, breastfeeding is less accepted once children start growing teeth (i.e., after the first 4–6 mo), and it is believed that continued breast milk intake after age 6 mo can lead to weaning problems. After 6 mo, the mother's milk is considered to be similar to water and is not nutritious for the infant. Lactating an infant after 6 mo is also perceived as a risk factor for debilitating the mother (studies 4–5).
The risk of empacho explains why caregivers usually begin complementary feeding with liquid foods, particularly bean broth (studies 1–5). In the first studies carried out, this belief was dominant; however, it was less frequently mentioned in the latter studies, perhaps due to the information transmitted in CCT-POP and/or the aggressive marketing of baby foods that occurred throughout Mexico.
When a child looked at food, this was interpreted as the child's desire to eat it and led caregivers to offer probaditas (small tidbits of food), which, according to them, served to accustom the child to food. Consistent with this, indigenous and rural caregivers did not conceptualize the existence of special foods for children. Indeed, children ate the same food as the rest of the family, only without hot spice (chile) (studies 1 and 3). Grandmothers and female community leaders explained that the correct way to feed IYC was by giving liquid consistency through minor adaptation of family foods, such as feeding only the broths from the beans that would be consumed by older children and adults. Another factor is that caregivers believed that each infant is unique and that feeding practices should therefore be adapted to the individual infant. This idea also contradicts standard recommendations.
We also documented the incorporation of high-energy and low-nutrient foods in children's diet from the youngest age. Caregivers reported giving IYC commercial breakfast cereals, infant formula and/or powder milk, industrial fruit juice, yogurt, biscuits, chocolate powder, and/or industrial infant foods (studies 2–4). Siblings, fathers, uncles, grandparents, and caregivers gave sweets, sodas, and chips to children (studies 2 and 4–5). This incorporation has been accompanied by the abandonment of traditional foods previously widely consumed, such as selected leaves (quelites), because they are considered to be “indigenous food” or “poor people's food” (studies 4–5). The valorization of high-energy and low-nutrient foods, associated with higher social status, may stimulate the offering of these foods by caregivers to their children.
Pattern of use of Nutrisano and attendance, understanding, and acceptance of education sessions of CCT-POP
Throughout the research projects, we observed minimal differences between experiences in rural, indigenous, and urban communities. The main results are presented in Table 4 and described in this section according to acceptance, fidelity, and penetration.
TABLE 4.
Main results related to acceptability and utilization of CCT-POP1
| Acceptability | Fidelity | Penetration | |
|---|---|---|---|
| Education sessions | Low acceptability:Caregivers complain about the conditions (e.g., under a tree and large group of participants) and its inadequate format (studies 1–3).Language barrier for indigenous caregivers (studies 1–3) or the use of technical language (studies 1–5).Caregivers do not identify the importance and relevance of the activities, and they assist because their presence is mandatory. | Low fidelity:Feeding practices (use of Nutrisano, complementary feeding, and consumption of nonnutritious snack foods and sweet beverages) of IYC are very different from WHO international recommendations (28, 29).Recommended practices are contrary to culturally normative practices (e.g., food sharing and the use of liquids) and to emerging “modern” practices (e.g., use of a bottle and consumption of nonnutritious snacks).Lack of training and attention to the primary care providers’ own knowledge related to nutrition topic.Caregivers received contradictory information from different sources. | Low penetration:Communication and cultural barriers and poverty contexts (studies 1–3).However, caregivers’ discourse included concepts of biomedicine. |
1 CCT-POP, Conditional Cash Transfer—Progresa–Oportunidades–Prospera; IYC, infants and young children.
Fortified complementary food: Nutrisano
Acceptability
Urban, rural, and indigenous caregivers showed high acceptability of Nutrisano because it was free and was perceived as an appropriate food. However, in the context of poverty, in which food is scare, Nutrisano was not targeted exclusively to IYC but was considered to be a food for the entire family (studies 1 and 3).
For some caregivers, the acceptability of Nutrisano was linked to their observations of improvements in their children's health, described as “growing faster,” “getting less sick,” and “having more energy.” However, other caregivers attributed negative side effects to Nutrisano (e.g., diarrhea), which constrained acceptance (studies 1 and 3). Caregivers’ perceptions of child acceptance of Nutrisano varied by flavors of the product, but preference and aversion patterns were not consistent among communities. Caregivers reported that their children showed signs of boredom and monotony with continued consumption of Nutrisano (studies 1 and 3).
Fidelity
Across studies, research revealed that the context of poverty, child care and child feeding social norms, and tradition hindered the adequate use of Nutrisano. For all the reasons mentioned previously, caregivers’ fidelity in using Nutrisano was generally low (studies 1–3) because it was to be prepared in a semisolid form and given exclusively to the beneficiary child. The observed noncompliance with the indications was driven by several factors. Caregivers perceived Nutrisano as a food, and sharing it with family members was important for them, but this contradicted the principle of targeting it to a specific child. In urban, rural, and indigenous communities, it was prepared mainly in a liquid form, which was compatible with common cooking and eating habits. This was particularly evident in indigenous communities because it was similar to common foods such as pozol, a drink prepared with cocoa, ground corn, or broths. In addition to sharing Nutrisano with older children and adults in the family, in a few cases, it was also given to animals (e.g., pigs) because their owners discovered that the animals grew better and faster when they consumed it.
Nutrisano has a very sweet taste, which was reported as a reason for rejection by children when it was prepared as recommended. These results were consistent across rural, indigenous, and urban areas and prompted some caregivers to find alternative ways to prepare it, such as adding more water or using it in recipes such as jelly or atole, a drink made mainly with corn. Feeding Nutrisano to the child in semisolid form, as recommended, required the use of a spoon. Caregivers expressed their lack of time to do this, given their many other household and child care responsibilities or because they worked outside the home. Caregivers believed that it was easier and less time-consuming to give Nutrisano to the child in a cup or a bottle. They also mentioned that they did not like to insist when the child did not like a food he or she was being fed. Finally, caregivers perceived Nutrisano as a food and not a nutritional supplement, and some of them used it as powdered milk, baby formula, or an ingredient to prepare desserts or beverages. This represented a way to save money. However, these practices were not in line with WHO recommended feeding practices (28, 29).
Penetration
We observed a high level of penetration of Nutrisano as an everyday food, as evidenced by its incorporation into family food practices. Moreover, given the patterns of use, the amount that was intended by the program to last for 1 mo was typically finished well before the next month's supply was provided.
Education sessions
Acceptability
In the first 3 studies, caregivers regularly complained about organizational and pedagogical aspects of the health and nutrition education sessions and described them as “boring.” This was reportedly due to the lack of adequate physical space for the sessions and difficulty understanding the facilitator's explanations. Usually, sessions were organized under a tree or on a patio, and large groups of caregivers would attend and have to stand for the duration of the presentation. In indigenous communities, sessions were presented in Spanish and many caregivers admitted having minimal or no comprehension. Caregivers also reported that the language used by the primary health care providers was too technical and prevented them from properly understanding the recommendations.
Caregivers did not always receive group education sessions about the importance of Nutrisano and instructions for its correct preparation or the recommendations related to age-appropriate child feeding. Caregivers reported receiving information on other health topics because attendance at these sessions was a “conditionality” of the program.
Fidelity
We did not systematically collect data to determine whether the primary care providers implemented the sessions as planned. From the caregivers’ perspective, however, we identified failures in the conceptualization and organization of the sessions. Generally, caregivers reported not being able to follow the recommended child feeding practices due to lack of understanding of the content and/or the language used, but also because of existing cultural barriers. Recommendations conflicted with cultural normative practices (e.g., food sharing and the use of liquids) and with widely adopted habits considered “modern” (e.g., use of a bottle and consumption of nonnutritious snacks).
We noted important gaps in the program's design, including a lack of training and attention to primary health care providers’ knowledge on nutrition topics (42, 43). Finally, caregivers received information from different sources (traditional knowledge and media and health care providers), which were often contradictory, thus leading to caregivers integrating the information from these different sources into an elaborate set of practices.
Penetration
The penetration of recommendations was often low because of communication and cultural barriers in poverty contexts. Nonetheless, when the final 2 studies were conducted, caregivers’ discourse included several concepts that had not been previously included, such as “vitamin,” “calorie,” “anemia,” and “nutrient.” This suggests the incorporation of certain concepts in caregivers’ knowledge frameworks (Table 4).
Discussion
Over time, the impact evaluation of CCT-POP transitioned to implementation research, focusing on understanding what, how, and why some aspects of the program were successful and others were not (44) and also on identifying bottlenecks and formulating recommendations to address them (45). Well-designed implementation research must recognize and incorporate an in-depth understanding of the sociocultural context in which programs are implemented (27, 46). As highlighted by Ottrey et al. (47), sociocultural studies are very helpful for understanding the complex relation between food/nutrition and their contribution to health issues. During the 13 y of research activities reviewed in this article and using our framework, we examined multiple sociocultural influences that impeded the intervention from improving the state of health and nutrition of IYC.
The main argument of this article is that by not taking into account the sociocultural dimension and aspects related to feeding practices in Mexico, the design and implementation were not sufficiently tailored to the population and, therefore, limited the strategy's impact (including the impact on nutritional indicators).
First, we documented part of the transformation of traditional feeding behaviors in Mexico, likely influenced by the ubiquitous availability and low cost of nonnutritious foods, which contributed to poor nutrition in IYC. These nonnutritious foods represent a challenge for improving IYC feeding practices. Our research also documented that social norms and traditional knowledge related to IYC feeding practices (breastfeeding and complementary feeding) hindered caregiver adoption of recommended feeding behaviors (e.g., empacho and probadita) (48, 49). In a study in the state of Morelos, which was independent of the CCT-POP's process evaluations, Monterrosa et al. (50) also identified probaditas and “children preferences” as key concepts in mothers’ knowledge framework for IYC feeding. Cheney et al. (51) showed that 1 of the reasons why Latina mothers of mostly Mexican descent did not always follow the recommendations of health professionals was to avoid conflict with the grandmothers of their IYC. The grandmothers usually are not aware of and do not have access to the information provided by the health sector, and their own cultural references in IYC feeding practices (e.g., feeding large portion sizes) are often obesity drivers. The authors conclude that the strategies based on the mother–child dyad are insufficient in these cultures because they do not consider and integrate the family environment. To a large extent, this recommendation also applies to the organization of nutritional education provided in CCT-POP, which included only single mothers.
However, throughout the years, we observed some modifications in the way IYC were fed in terms of consistency, especially among non-indigenous populations. This change may be due to a diffusion of semi-liquid preparations and potentially to the implementation of communication interventions to improve Nutrisano and food marketing aimed at IYC feeding.
Therefore, we focused our analysis on how sociocultural aspects influence the pattern of use of Nutrisano and understanding and acceptance of education sessions, which are both elements of the health and nutrition component of CCT-POP. In the case of Nutrisano, we demonstrated how sociocultural aspects related to feeding practices negatively affected the adequate preparation and consumption of Nutrisano and led to noncompliance with the official recommendations for use. The problem with Nutrisano was a “fidelity” issue rather than one of “acceptance” because although caregivers incorporated it in family food practices, the targeted IYC did not consume it as recommended, in terms of quantity and consistency. We identified 2 principal cultural barriers: food consistency and the practice of food sharing. Liquid preparations for IYC foods have been reported in Mexico (50), as well as in other areas of the world (52), although the cultural explanations for this practice differ from the specific emic perspective in Mexico (31). For example, in Nigeria, mothers are concerned about the introduction of “heavy” solid foods, such as yam, because they are concerned that heavy foods will make infants heavy to carry (27), in contrast to Mexico, where caregivers are concerned about empacho. The value of sharing food was the other key cultural element identified among indigenous and mestizo populations of our study. This element directly contradicted the CCT-POP principle of targeting Nutrisano for beneficiaries’ children (17). The contradiction created a significant dilemma for caregivers because they were asked not to share the supplement with other children of the household. This emphasis on sharing food likely created a culture barrier to fidelity in the use of Nutrisano. This sociocultural analysis showed that Nutrisano is not the ideal supplement for the CCT-POP population, considering values and norms related to food.
In the case of education sessions, the culture gap between biomedicine and local cultures, as well as low educational levels of the beneficiary population, partly explains why the design of the nutrition and education sessions was not adapted to local population and therefore not as effective as hoped. Our studies revealed that caregiver boredom, linguistic barriers, the use of technical language, and the education format all constrained acceptance of the education component. By offering sessions that did not take into account the low educational level of the caregivers, nor their culture of origin, in addition to performing these sessions in poor conditions (e.g., outside under a tree), the opportunity to appropriately inform caregivers on the use of Nutrisano, but also on other topics such as breast and complementary feeding practices, was missed.
In 2006, CCT-POP changed the session format to include the active participation of caregivers, as well as workshops on self-care and health (12). However, no evaluation of the “new” education session's format has been published.
With studies 4–5, we evidenced also that the technical knowledge of the primary care providers was not always current with regard to WHO recommendations (28, 29) and needed to be addressed (42, 43).
Reflecting on the results of our studies, we stress that systematically exploring the emic perspectives of program beneficiaries is a challenge that requires consistent resources and sensitivity to the respondents. Due to space limitations, we did not present data related to the sociocultural context contributing to inadequate maternal nutrition, despite its importance in designing a communication and training plan to strengthen primary health care providers’ counseling abilities and technical knowledge. However, these aspects have been addressed in a systematic review of studies conducted throughout the world, showing that food intake during pregnancy and lactation is also shaped by sociocultural factors (53).
In conclusion, several contextual and sociocultural factors, including the central roles of poverty, patriarchal family organization, high availability of nonnutritious food, social norms, and certain aspects of traditional knowledge, shape child-feeding practices. Communication barriers with the biomedical culture limited the program's potential to overcome these issues via the health and nutrition education component. This article also highlights the importance of understanding the local culture and its implications for IYC in order to strengthen or design local and national public health programs.
Acknowledgments
Acknowledgments
The authors’ responsibilities were as follows—FLT and AB: conceptualized the study and developed the framework; FLT, AB, and IBG: collected data and interpreted study results; AB, AG-G, IBG, RA, and CJR: collaborated in writing the manuscript; FLT: wrote the manuscript and had primary responsibility for the final content; LMN and GHP: provided key insights for the final manuscript; and all authors: read and approved the final manuscript.
Footnotes
Funds for the research reported in this article were provided by the National Coordination of the Progresa–Oportunidades–Prospera (now called the Prospera Programa de Inclusión Social), Secretary of Social Development, Government of Mexico, Mexico City. Funding for the supplement was provided by the National Institute of Public Health, Mexico, and the Global Alliance for Improved Nutrition.
Author disclosures: FLT, AB, AG-G, IBG, RA, CJR, LMN, and GHP, no conflicts of interest.
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