Table 4.

Sociocultural drivers and determinants of acceptance and adoption for consumers of biofortified crops in low- and middle-income countries

Reference	Country	Study Population	Method and Study Design	Results	Conclusion
Sweet potato
Mazuze (2004)61	Mozambique	Producers and consumers: Adults who had received OFSP vines in 2000, Gaza Province,  mean age: 42 y; n = 150	Cross-sectional study. Structured questionnaire (about growing and adoption of OFSP)	83% of respondents were aware of the nutritional benefits of OFSP. A larger share of land (83%–86%) was planted with white vs OFSP varieties, attributed to unavailability, limited propagation capacity, and lower drought tolerance of OFSP. Reasons for planting OFSP were perceived high yield, better taste, and desire to experiment with new varieties. Adoption rate varied per season from 38% to 71% and related to participation in field days and demonstration activities, the number of times vines were received, number of OFSP varieties, cultivated area, and rainfall	OFSP adoption can be improved by providing credit for animal traction, improving drainage systems, and providing access to more drought-tolerant vines. More research into postharvest processing and storage of roots would help to reduce the low availability of roots due to seasonal planting
Low et al. (2007)24	Mozambique	Producers and consumers: Children, 4–38 mo, 47% F; n = 741	Quasi-experimental prospective controlled trial (2 y) Intervention: Vines distribution, training Outcome: Change in serum retinol concentration, OFSP plot size, OFSP consumption, production OFSP	Production expanded from 33 to 359 m2; participation in OFSP production and sales increased in intervention households but decreased in control households; 90% of intervention households grew OFSP compared with 11% in control; SP production increased from 73 kg to 127 kg (71% OFSP); Percentage households selling increased from 13% to 30%, but no increase for households; > 50% of children in intervention consumed OFSP at least 3 out of 7 d as compared with 4%–8% of control children	Integrated promotion of OFSP has potential to increase adoption of OFSP and increase consumption
Hotz et al. (2012)22	Mozambique	Producers and consumers: Children, 0–5 y, 47% F; n = 386 Caretakers, 100% F; n = 393	Randomized controlled effectiveness trial (2.5 y) with 3 arms: control, OFSP distribution plus 1 y or 2 y intensive training	77% adoption; share of OFSP cultivated area increased from 9% to 56%; OFSP intake significantly increased in intervention groups for 6–35 mo (46 g/d), 3–5.5 y (48 g/d), and women (97 g/d) compared with control; no difference in effect between the 2 intervention groups	OFSP is well adopted and consumed after introduction; group-level trainings in nutrition and agriculture could be limited to the first year of project without compromising impact
Hotz et al. (2012)23	Uganda	Producers and consumers: Children, 6–35 mo; n = 265 Children, 3–5 y; n = 578 Women, n = 578	Randomized controlled effectiveness trial (2 y) with 3 arms: control, OFSP distribution plus 1 y or 2 y intensive training	OFSP intake increased in both intervention groups (P < 0.01), accounting for 44%–60% of vitamin A intake at follow up. Prevalence of inadequate vitamin A intake was reduced among children 6–35 mo (> 30 percentage points) and women (> 25 percentage points), with no difference between intervention groups	SP was adopted and grown by farmers resulting in incorporation of OFSP into the diets of women and children with a measurable impact on vitamin A status in children
Fetuga et al. (2013)62	Nigeria	Producers and consumers: Households from Southwestern Region of Nigeria, > 4 y;  n = 300 Sweet potato processors  n = 23 (17 farmers)	Cross-sectional study. Structured questionnaire (OFSP processing, OFSP amala (stiff porridge) consumption, OFSP awareness)	48 (16%) and 46 (15%) respondents had heard of and seen OFSP; 31 had tasted it, and most of them (93.6%) liked the taste. Sex, age, or education level were not associated with OFSP awareness. 98.3% of respondents were not aware of the health benefits of OFSP, but 75.7% were willing to taste if available. 15 of 23 respondents engaged in SP processing used yellow-fleshed SP. Color (n = 14), availability (n = 7), and taste (n = 2) were drivers of choice for the variety of SP. Current processing methods for preparing amala from SP result in inferior sensory quality (appearance and texture), which is solved by mixing SP flour with other flours (yam, cassava, plantain, and wheat)	Awareness of OFSP was very low among respondents and knowledge about its health benefits almost nonexistent. Strong indication that people were willing to consume OFSP if made available. In Nigeria, both awareness and availability should be targeted. Improvement and standardization of the processing method could benefit the use of OFSP in amala preparation, providing a cheaper alternative to amala prepared from other types of flour
Gilligan et al. (2014)63	Uganda	Producers and consumers: Households with a child 3–5 y old, M + F, mean age: 35 y; n = 1176	Household survey on adoption rate and comparison of intrahousehold bargaining power based on asset ownership and control over land use	Adoption rate in season 1 was high (90%) but declined to 69% in season 4, varying per district, due to vines drying up, no access to new planting material, insufficient availability of labor available, and dislike of crop. Among female-headed households (11%), exclusive control over land was positively associated with OFSP adoption. This association was absent among male-headed households. OFSP adoption was associated with age of the head of household, knowledge of vitamin A, and total land area cultivated with sweet potato. Women with a high share of nonland assets ownership were less likely to grow OFSP	OFSP was well adopted in this region of Uganda. Female bargaining power does not unambiguously increase the probability that a household adopted OFSP in response to the project. The probability of adopting OFSP was lowest on parcels exclusively owned by men and largest on parcels jointly owned by males and females with women in the lead. Engaging with both men and women might be the best strategy to promote adoption
De Brauw et al. (2015)69	Mozambique	Producers and consumers: Households in Zambezia Province,  M + F; n = 720	Randomized controlled effectiveness trial (2.5 y) with 3 arms: control, OFSP distribution plus 1 y or 2 y intensive training	Children in households with more participation had higher dietary vitamin A density, and slightly higher mean micronutrient density and dietary diversity	Intensity of participation in extension activities is associated with larger project impact
Yanggen and Nagujja (2006)64	Uganda	Producers and consumers: Adults in intervention and nonintervention areas in 4 regions; n = 160	Cross-sectional survey with questionnaires, key-informant interviews and focus group discussions (women only, men only, and mixed groups)	64% of farmers adopted OFSP in intervention compared with 22% in nonintervention areas. Main OFSP production constraints were pests and diseases (especially weevils), drought, and availability of vines (no commercial vine distribution), followed by lack of capital and labor. Major favorable characteristics farmers look for are yield, sweet taste, early maturity, and drought resistance, followed by consumer characteristics like tuber quality, good price, high dry matter, color, good storability, low fiber, and nutritional content. Nutrition content comes last as favorable characteristic, only mentioned by women (as 4th most important) but not by men. Most important information sources were nongovernmental organizations, fellow farmers, and agricultural extension workers	Nutrition concerns cannot be depended upon to push the adoption of OFSP. OFSP must be competitive with white and yellow varieties in terms of agronomic, consumer, and economic characteristics (in terms of yields, taste, price, etc) if it is to be successful. Nutrition education campaigns must be an integral part of the promotion of OFSP
Machira et al. (2013)70	Kenya	Producers and consumers: Key persons involved in OFSP projects in antenatal care services in western Kenya;  n = 66	Interviews and focus group discussion with key persons about an integrated nutrition, agriculture, and health intervention that delivers OFSP through antenatal care services in western Kenya	Food security and health benefits were most recognized by participants. Mothers indicated that their children were less susceptible to disease and were more energetic; shorter maturation and higher yield of OFSP were also valued. Health workers perceived higher antenatal care attendance and increased healthcare-seeking behavior as benefits. Challenges were distance to health facility, misperceptions (OFSP = contraceptive), need for continuous community sensitization, and increased workload with remuneration for community volunteers and vine multipliers	Perceived benefits and motivating factors outweighed challenges of integrating OFSP with antenatal care service
Maize
Tschirley and Santos (1995)65	Mozambique	Consumers: Low-income urban households; n = 400	Cross-sectional study	22% of households consumed predominantly yellow maize. Consumers of yellow maize had substantially lower income than white maize consumers. Highest income consumers were the least likely to consume yellow maize	Yellow maize is well accepted, especially among poor consumers
Muzhingi et al. (2008)66	Zimbabwe	Consumers: Rural and urban households; n = 316	Cross-sectional study (in-depth questionnaires, focus groups discussion)	Yellow maize was known by most respondents but mainly from food aid. Link with food aid and bad taste (due to organoleptic changes during storage) were seen as negative aspects of yellow maize. Nutrition information on vitamin A and taste were significant contributors to acceptance	Acceptance could be improved if nutrition knowledge was increased
Khumalo et al. (2011)51	South Africa	Consumers: Adult females from Limpopo Province, > 18 y; n = 48	Focus group discussions (consumer attitudes, perceptions, and practices) of maize porridge prepared from several types of white and yellow maize meal	Preference for yellow maize related to knowledge of the presence of vitamin A in yellow maize meal (acquired during previous training in 2004), availability (during drought as relief food), and price determined whether yellow maize is bought	Acceptability of yellow maize mainly related to nutritional reasons. Availability was the largest obstacle
Govender et al. (2014)52	South Africa	Consumers: Female infant caregivers; n = 21	Focus group discussions (acceptability of provitamin A–biofortified maize for preparing maize porridge for their infants)	Yellow maize is not sold in supermarkets, suggesting that white maize is of better quality. Yellow maize considered to be for poor people or animals. Affordability, availability, and health benefit were reasons for being willing to give provitamin A–biofortified maize porridge to their infants	Affordability, availability, and health benefit were important determinants of accepting provitamin A–biofortified maize as infant food
Schmaelzle et al. (2014)25	Zambia	Consumers: Children 5–7 y, n = 136	Randomized controlled feeding trial with 3 arms: porridge (nsima) of orange maize and placebo oil; of white maize and placebo oil; of white maize and vitamin A supplement	Orange group consumed less nsima (276 ± 36 g) than white groups (288 ± 26 g and 288 ± 25 g, P = 0.08), with consumption fluctuation between weeks, and no difference in total food intake and relish intake. Mothers and staff preferred orange maize because of softer structure and sweeter flavor than the white maize; because of texture it was difficult to use orange maize nsima to scoop up relishes	Implementation and adoption of new and biofortified foods is possible with promotion, especially in very traditional cultures that are deeply connected to their food
Cassava
González et al. (2009)58	Brazil	Consumers: Households in northeast Brazil, mean age: 40 y; n = 414	Cross-sectional study on genetically engineered cassava. Structured questionnaire after explanation about genetically engineered yellow cassava	25% of respondents had ever heard about genetic engineering, 22% found it a possible health risk. Age, trust in authorities, perceived health risk, and access to media influenced consumer support of genetically engineered crops	Attitudes toward genetically engineered biofortified yellow cassava is positive
González et al. (2011)59	Brazil	Producers and consumers: Adult farmers;  n = 76 Adult farmers who received seeds for public awareness campaign in northeast Brazil; n = 40	Cross-sectional study. Participatory research and questionnaires evaluating adoption	15% of farmers planted the yellow cassava 1 y after the release (early adoption rate), and 62% said they would do so next year (potential/intentional adoption rate), because of the better nutritional content. Reasons for not adopting were low availability of seeds and taste. From the farmers who received seeds, 63% planted them. Key factors were receiving information, involvement in previous participatory research, and knowledge about nutritional advantages	To increase early adoption of yellow cassava, it is important to increase the nutrition knowledge, have high availability of seeds, and use information and socialization among producers
Uwiringiyimana (2012)67	Benin	Consumers: Mothers of primary school children,  15–49 y; n = 147	Cross-sectional survey. Questionnaire (intention to eat yellow cassava and its determinants)	90% had intention to prepare yellow cassava for their children 2 or more times a week. Health behavior identity, knowledge, and perceived susceptibility predicted intention to consume yellow behavior, as well as cues to action	Intention can be increased by increasing knowledge on vitamin A deficiency and health benefits of yellow cassava and increasing positive triggers as recommendations from influential people and educational campaigns
Talsma et al. (2013)20	Kenya	Consumers: Caretakers of schoolchildren, 90% F, 18–50 y; n = 140	Cross-sectional survey. Questionnaire (intention to eat yellow cassava and its determinants)	Almost all had intention to prepare yellow cassava for their children, of which 64% were willing to do so 2 or more times per week. Knowledge about provitamin A–rich cassava and its relation to health was a strong predictor of health behavior identity. Worries related to bitter taste and color, belief about being in control to prepare cassava, and activities such as information sessions about provitamin A–rich cassava and recommendations from health workers predicted intention to consume provitamin A–rich cassava	The yellow color is no barrier for consumption. Intention to consume can be increased by reducing barriers (like worries about color, taste, texture, and bitterness); by increasing knowledge on vitamin A deficiency and provitamin A–rich cassava; by empowering mothers to decide what to cook; and by involving health workers in the promotion of yellow cassava
Rice
De Steur et al. (2013)71	China	Consumers: Adults in Shanxi Province, 20–69 y, M + F; n = 588	Cross-sectional study questionnaire (perceptions on genetically engineered folate-biofortified rice)	Taste and health are the most important attributes for rice purchase, followed by price and external appearance. Respondents answered correctly on 42% of the questions concerning knowledge of genetically engineered foods. 62% of respondents were in favor of genetically engineered folate biofortification of rice. A negative change in taste decreased this proportion to 28%, environmental impact decreased it to 29%, price decreased it to 35%, availability decreased it to 41%, external appearance decreased it to 46% and cultivation potential decreased it to 50%	Initial acceptance rate would be halved if genetically engineered folate-biofortified rice would have a negative effect on taste, price, or the environment. Multiple attributes should be taken into account in the development of biofortified crops
De Steur et al. (2015)60	China	Consumers: Adults in Shanxi Province, 43% F; n = 451	Cross-sectional study. Questionnaire on genetically engineered rice, including false/true statements, 5-point hedonic scale statements, a knowledge score, 4 additional scores (benefits, risks, safety, price), overall trust scores for information channels or sources	66.5% in favor of nutritionally enriched rice; 39% had limited knowledge about genetically engineered food; 3 groups of consumers: enthusiasts (14%: health, lower pesticide use, males, rural, farmer), cautious (41%; positive on safety, females, urban); and opponents (45%; side effects, including biodiversity, females, low income, rural). Enthusiastic respondents have a more positive attitude	There is a promising (segmented) market potential for second-generation genetically engineered products
Beans
Asare-Marfo et al. (2016)68	Rwanda	Producers and consumers: Bean-producing households in 120 random villages, > 21 y, 65% F; n = 19 575	Cross-sectional impact assessment study by listing exercise to identify HIB growers among bean-producing households with questionnaires	Over the last 5 y, of the 93% households that grew beans, 29% respondents indicated to have grown an HIB variety. Out of the 84% of farmers who indicated to have grown beans in the second season of 2015, 21% have grown at least 1 HIB variety. Within the country this varied by location, with Eastern Province having higher adoption rates. Adoption rate was further determined by yield, easiness to farm the variety, commercial value, and availability of seeds. The main source of first planting material were the markets (41%) and social networks (23%)	Adoption rates of HIB varieties in Rwanda are very promising

Abbreviations: F, female; HIB, high-iron bean; M, male; OFSP, orange-fleshed sweet potato; SP, sweet potato.