Formative research for the development of a market‐based home fortification programme for young children in Niger

Abstract

The objective of this formative research was to assess the acceptability of a micronutrient powder (Sprinkles^®) and a lipid‐based nutrient supplement (Nutributter^®), and to explore people's willingness to pay for these products in a resource‐poor context like Niger. In four sites, 84 focus group discussions among mothers, fathers and grandmothers of children 6–23 months were conducted, as well as 80 key informant interviews of mothers who participated in a home study where their children 6–23 months were given either Sprinkles^® or Nutributter^® to use either for a period of 4 weeks, or they were given both products over the 4‐week period, i.e. Sprinkles^® for 2 weeks and Nutributter^® for an additional 2 weeks. The mothers understood how to use the products and generally used the products correctly. Both products were highly acceptable to adults and most children. In Niamey, where the 4‐week home study used both products for 2 weeks each, the mothers tended to prefer Nutributter^®. The mothers who used either product were pleased with the improvements they saw in their children's health, including increased appetite, weight gain and increased energy and activity. A few mothers were concerned with how they would be able to provide for their child's increased appetite. Most participants across all four sites reported that they would be willing and able to afford to buy a single sachet of either Sprinkles^® at a cost of US$0.03 or Nutributter^® at a cost of US$0.08 several times a week. This study provides evidence that both of these products were are highly acceptable in different settings in Niger and suggests that delivery of Nutributter^® or Sprinkles^® at a low or subsidized cost through a market‐based system may be possible in Niger, if an appropriate distribution system can be identified.

Introduction

Inadequate nutrition among young children is a significant global public health problem, with more than one‐third of deaths among children under the age of 5 years due to undernutrition (Black et al. 2008). Among children that survive, undernutrition has long‐term consequences including growth faltering, lower educational attainment, reduced economic productivity and poorer reproductive outcomes (Victora et al. 2008). The key period for intervening to promote optimal growth and development of a child is throughout pregnancy and during the first 2 years of life (Victora et al. 2010). The World Health Organization recommends exclusive breastfeeding until 6 months of age, at which point, breast milk alone is no longer sufficient, and diverse complementary foods need to be introduced in addition to continued breastfeeding (WHO 2002). Throughout the developing world, access to nutritious, energy‐dense complementary foods is generally limited.

Several products have been developed to increase the nutrient intake of young children 6–23 months of age. These include micronutrient powders (MNPs), such as Sprinkles^®, and lipid‐based nutrient supplements (LNSs), such as Nutributter^®. MNPs have no taste or colour, which results in the ability to feed children the product without their knowledge. The wholesale cost of a sachet of MNP typically costs about US$0.02 per day ¹ . A systematic review of efficacy studies showed that Sprinkles^® is very effective at reducing iron deficiency, and decreases the prevalence of anaemia by half (Dewey et al. 2009). Sprinkles^® has not been shown to have a significant effect on growth but has been shown to have an effect on motor development, as evidenced by an increased prevalence of children walking at 12 months of age (Adu‐Afarwuah et al. 2008).

Nutributter^® differs from Sprinkles^® in that it provides energy, fat (including essential fatty acids) and protein, in addition to micronutrients. A daily serving of Nutributter^® (20 g) provides about 100 calories, which is approximately one‐half to one‐quarter of the calories needed from complementary foods for a breastfed child aged 6–23 months (Chapparro & Dewey 2010). Nutributter^® has a sweet peanut taste, so it will affect the taste of any food that it is mixed into; additionally, it can be eaten alone. A serving of Nutributter^® is more expensive than Sprinkles^®, at a wholesale price of approximately US$0.08 per day ² . LNSs have not been used or studied as extensively as Sprinkles^®. However, a few trials, one using Nutributter^® (Adu‐Afarwuah et al. 2008) and others using a similar LPS (Kuusipalo et al. 2006; Phuka et al. 2009), were shown to reduce iron deficiency and anaemia and to improve growth and motor development (Dewey et al. 2009).

In Niger, the mortality rate for children under 5 years is one of the highest in the world, at 198 deaths per 1000 live births. Among children 6–23 months, 91% are anaemic, 49% are stunted and 18% are wasted (National Institute of Statistics and Macro International Inc 2007). Entirely free programmes are increasingly unsustainable due to limited government and donor funds, and other approaches are needed to support nutrition interventions. Multiple partners were interested in investigating the possibility of establishing a market‐based distribution of micronutrient supplements designed for preventing undernutrition among young children. Before developing such a programme, extensive formative work was needed for several reasons: (1) to update ethnographic work on infant and young child feeding; (2) to assess if Sprinkles^® and Nutributter^® were acceptable to the population and if there were any problems with use; (3) to explore whether families would be willing to purchase preventive health items for young children given families are accustomed to receiving free health services for children under 5 years of age; and (4) to explore possible channels for a market‐based distribution. The purpose of this paper is to describe the results of the formative work related to the acceptability of the products and the willingness of users to pay for these products in a market‐based system.

Key messages

• • Deficiencies of macro‐ and micronutrients among young children in Niger are a public health concern. Strategies are needed to improve the nutritional adequacy of complementary foods in addition to supporting exclusive breastfeeding for children 0–6 months of age and continued breastfeeding for at least 2 years.
• • Nutributter^® was the preferred product, although both Sprinkles^® and Nutributter^® were well accepted by children 6–23 months and their mothers during a 4‐week home study. The focus group participants also liked both products but tended to prefer Nutributter^®.
• • Participants of the 4‐week home trial and also the focus groups across all four sites were prepared to pay several times a week for the products.
• • Future studies should look at the use of home fortificants and their interaction with infant and young child feeding practices.

Methods

Location

Four sites with different levels of urbanization were chosen within two primary locations. Within Niamey, the capital, two sites were selected; Gamkalley, an urban industrial area, and Goudel, a peri‐urban area where residents tend to be involved in some agricultural activities. In both of these sites, Djerma is the predominant language used. In the second location, the district of Dogondoutchi in the Dosso region, Doutchi city and Soucoucoutane village were selected, in order to get representation of a larger town and a very dry rural village, respectively. The predominant language spoken there is Hausa, which is the principal language in Niger.

Qualitative data collection

Data collection occurred from July to November 2009. Purposive sampling was used to identify the primary target groups: mothers, fathers and grandmothers of children 6–23 months of age. In each study site, qualitative data collection techniques included focus group interviews, key informant interviews and observations. All participants gave informed verbal consent. After the informed consent, but before the interviews began, demographic data were collected from all participants. Bilingual or multilingual‐trained female data collectors conducted all interviews in either Djerma or Hausa. During the interview, notes were written in French as Djerma and Hausa are not generally written languages. The French notes were later translated into English by a professional translation company.

The content of seven focus group interview guides tailored for the three target groups centred on health, nutrition and feeding practices of young children; household dynamics related to resources' decision making and spending priorities; and reactions to the two products including taste, first impressions and cost (Table 1). For each topic and target group, three focus group interviews with five to eight participants each were carried out in each of the four sites, resulting in a total of 84 focus group interviews.

Table 1.

Summary of focus group interviews by topic and target group

No.	Topic	Target group	Number of focus groups in each site	Numbers of focus groups in all sites
Guide 1	Health and nutrition	Mothers of children 6–23 months	3	12
Guide 2	Household dynamics	Mothers of children 6–23 months	3	12
Guide 3	Reactions to products	Mothers of children 6–23 months	3	12
Guide 4	Health, nutrition and household dynamics	Fathers of children 6–23 months	3	12
Guide 5	Reactions to products	Fathers of children 6–23 months	3	12
Guide 6	Health, nutrition and household dynamics	Grandmothers of children 6–23 months	3	12
Guide 7	Reactions to products	Grandmothers of children 6–23 months	3	12
Total			21	84

Additionally, a 4‐week home study was conducted among 20 households with children 6–23 months of age in each of the four sites, for a total of 80 households. All children 6–23 months within the selected household were eligible to participate. A household list was drawn up in each of the four sites, and households were selected based on gender, age, and demographic and geographical characteristics so that the households would be the representative of their community. The mothers were the respondents in key informant interviews conducted at enrolment, midpoint and end of the home study. A household observation of mothers using the product was also conducted during the midpoint visit. In each of the two sites in Doutchi, the mothers received either Sprinkles^{® 3} or Nutributter^{® 4} but not both, to use daily for 4 weeks. In each of the two Niamey sites, a crossover design was used, where participants were given both Sprinkles^® and Nutributter^® to use for 2 weeks each. To ensure that the order in which the families received the products did not affect their impressions, the half started with Sprinkles^®, while the other half started with Nutributter^®. The two different methods were used in order to allow some mothers a longer time to experience the products (Doutchi), while others would be able to directly compare the products (Niamey).

Regimen and product information given to participants of the focus group interviews and the 4‐week home study

In both the focus group discussions and in the 4‐week home study, participants were given information about the composition of the products. The field workers read the following statement to the participants regarding Sprinkles^®: ‘Sprinkles^® are a fine powder that contains several vitamins and minerals that can be mixed into a child's food’; and regarding Nutributter^®: ‘Nutributter^® is a peanut‐based spread that is made from peanuts, oil, milk powder and sugar. It also contains several vitamins and minerals. Nutributter^® can either be eaten on its own or it can be mixed into food’. For both products, participants were informed that Sprinkles^® and Nutributter^® have been used in various countries to reduce children's anaemia, increase their appetite, increase their energy and, generally, improve their health.

During enrolment into the 4‐week home study, field workers demonstrated how to use the product, including opening the products and mixing them into a small quantity of food, and explaining that the food mixed with either product should best be used within 30 min of mixing. The mothers were also instructed that Nutributter^® could be given directly without mixing it into food.

Due to concerns that supplemental iron may exacerbate infections, particularly malaria, in iron‐sufficient children, and that folic acid may interfere with the efficacy of antifolate, anti‐malaria therapy (WHO Secretariat on behalf of the participants to the Consultation 2007), the Sprinkles^® and Nutributter^® formulations used in this formative work were modified to reduce iron content and remove folic acid. The amount was reduced to be similar to supplying what would be found in normal complementary foods. Table 2 shows the nutrient content for both products. As a result of this change in the formulation, a twice‐daily regimen for the products was used, in contrast to previous studies that gave more iron and used the product only once per day. For Sprinkles^®, the mothers were instructed to mix one sachet into their child's food twice per day (two sachets per day total). For Nutributter^®, mothers were instructed to either mix into food or give directly to their child one sachet per day, splitting the sachet so as to give half in the morning and half in the afternoon or evening.

Table 2.

Nutrient composition of Sprinkles^® and Nutributter^® used in this study

Nutrient	Sprinkles® (total per day – two sachets)	Nutributter® * (total per day – 1 × 20 g sachet)
Vitamin A (vitamin A acetate)	300 mcg	0.4 mg
Vitamin B1 (thiamin mononitrate)	0.5 mg	0.3 mg
Vitamin B2 (riboflavin)	0.5 mg	0.4 mg
Vitamin B6 (pyridoxine)	0.5 mg	0.3 mg
Vitamin B12 (cyanocobalamin)	0.45 mcg	0.5 mcg
Vitamin C (ascorbic acid)	35 mg	30.0 mg
Niacin (niacinamide)	6.0 mg	4.0 mg
Copper (copper sulphate)	0.6 mg	0.2 mg
Iodine (potassium iodide)	50 mcg	90.0 mcg
Iron (ferrous fumarate)	6.0 mg	4.5 mg
Zinc (zinc gluconate)	5.0 mg	4.0 mg
Vitamin D3 (cholecalciferol)	5.0 mcg	–
Vitamin E	6.0 mg	–
Selenium	–	10.0 mcg
Magnesium	–	16.0 mg
Calcium	–	100.0 mg
Phosphorus	–	82.1 mg
Potassium	–	152.0 mg
Manganese	–	0.08 mg
Pantothenic acid	–	1.8 mg
Energy	–	108 Kcal
Proteins	–	2.6 g
Fats	–	7.1 g

^* 20 g of Nutributter^® also provides a minimum of 1.29 g Linoleic acid and 0.29 g alpha‐Linolenic acid.

For both products, participants were given detailed information and demonstration on how to use the products. They were also advised that they may notice their child's stool becoming darker or that he or she has loose stools for a few days, which was normal.

Data management and analysis

English transcripts of all data were uploaded into Nvivo 8 (QSR International, Cambridge, MA, USA). Three authors (K.T., C.P. and B.H.) read all the transcripts and coded and analysed the data. Interviews were first coded by questions and then for key themes. At least two authors coded and analysed each section of data, and the discrepancies were resolved by discussion. Key quotes were identified that represented the majority's view. Analyses were initially stratified by site and target group; and results were combined where there was little difference across sites, and unless otherwise noted, results being presented were found to be consistent across sites.

Ethical review

Ethical approval was obtained from the Niger Ministry of Health. Additionally, the United States Centers for Disease Control and Prevention determined that the project was consistent with the standards for public health practice.

Results

In total, 84 focus group discussions were held with a combined total of 232 mothers, 130 fathers and 147 grandmothers.

The average age of all mothers participating in the focus group discussions was 27 years (range 15–47). The majority had no primary education. Ninety‐three per cent of mothers were married, of which, 28% were in a polygamous marriage. The average age of fathers was 39 years (range 24–65); all were married and 19% were polygamous. The average age of grandmothers was 58 years (range 30–110).

Key informant interviews were conducted with 80 mothers who participated in the 4‐week home study. Of these, 77 completed all three interviews at enrolment, midpoint (plus observation) and exit. Of the 83 children enrolled in the 4‐week study, 36 were between 6 and 12 months of age (Table 3).

Table 3.

Characteristics of 80 mothers and 83 children participating in the 4‐week home study

Variable	Site
	Dogondouchi		Niamey
	Douchi	Soucoucoutane	Goudel	Gamkalley
Mean age of mothers (years) (range)	30.5 (19–45)	25.7 (16–40)	33.1 (21–48)	26.9 (18–37)
Mean age of infants (months)	13.2	12.7	13.6	16.2
Number of infants 6–11 months of age	9	10	11	6
Mean HH size	9.0	11.0	8.7	7.9
Received primary education %	55	10	45	60
Polygamous marriage %	45	40	35	5
Work outside the home %	75	40	55	35

HH, (Household), the basic residential unit in which activites are organised and carried out.

Purchase of special items for young children

Many families do buy foods or treats specifically for young children that are apart from the family bowl or what is given to older children. The money usually comes from the father, but if the father does not have money, many mothers do have some form of income generation, such as extraction of peanut oil or selling fritters, and they will use this money to buy foods for young children. The foods purchased for young children include Solani (liquidy yogurt), bean fritters, bananas, potatoes, eggs, cookies, oranges and canned milk. Families, especially in both Niamey sites and Doutchi city with access to vendors, often buy these small quantities of food multiple times throughout the day, with the cost of each item usually ranging from 25 CFA to 125 CFA (US$0.06–US$0.25). The reason they gave for buying these foods for young children was to promote the child's growth, health and nutrition.

In all sites, except for Soucoucoutane (rural village), participants said that they purchase preventive health products. These included mosquito nets, nivaquine and paracetamol (acetaminophen) for malaria, Grandibien^® (similar to Nutributter^® except that it has cocoa rather than peanut base and is targeted towards slightly older children) and Misola (local fortified complementary cereal for children). In Soucoucoutane, many of the participants said they do not purchase preventive health products because mosquito nets are free and there are no other preventive health products available in the village.

Product acceptability

Both Sprinkles^® and Nutributter^® were found to be acceptable and beneficial in all four sites. At the end of the home study in Doutchi, where mothers used only one of the products for the entire 4 weeks, all mothers liked the product that they used and would continue to use that product if it were available locally.

In response to Sprinkles^® one mother said, ‘I saw the usefulness of Sprinkles^® and I would recommend all mothers look for it for their children. And if it is possible, we would like it to be available on the market as soon as possible’ (Mother in Doutchi, 4‐week study). Mothers said that Sprinkles^® was easy to use, and several liked that the product had no taste or smell and did not change the taste of the food. A barrier that was encountered to using Sprinkles^® is that food is required for the Sprinkles^® to be mixed into. In Soucoucoutane, there were instances where a mother was not able to give her child Sprinkles^® because she simply did not have any food.

Regarding Nutributter^® a mother said, ‘all that I want to say is to thank you for having given our children these very important foods. Really, we saw its importance and we appreciate it a lot’ (Mother in Soucoucoutane, 4‐week study). Few participants found Nutributter^® unacceptable.

For both products, a few mothers mentioned that they disliked the fact that their children had loose stools in the first few days of use. However, most also said that because they were warned about this side effect, they were not concerned.

Overall, there were very few concerns for either product. When asked if the participants had any questions or concerns about using the products, the topics raised regarding the use of Sprinkles^® and Nutributter^® are presented in Table 4.

Table 4.

Questions/concerns about use of Sprinkles^® and Nutributter^® among mothers participating in the 4‐week home study

Questions asked about both products
Is it necessary to take my child to the health centre if their soft stools/mild diarrhoea persists?
What would happen if my child consumed too much of the product at one time?
Will my child's health suffer when the study ends and there are no more products?
Will using the product prevent anaemia even if the child becomes sick while using the product?
What will happen if I forget to give my child the product every day?
What will happen if I give my child food mixed with the product after 30 mins has passed?
Where can I buy more and how much will it cost?

Questions asked about Sprinkles®
Can Sprinkles® make the body swell?
Can I give my child two sachets in one meal?

Questions about Nutributter®
Can you give one bag in one go rather than splitting it?
Will my child's increased appetite continue once the Nutributter® is finished?

Perceived effects of products

Participants in the home study reported noticing changes in their children within the first 2 weeks of using Sprinkles^® and Nutributter^®. In Doutchi, where children only used one product for the entire 4 weeks, the same effects were noticed by mothers of children using Sprinkles^® and those using Nutributter^®. Almost all mothers in the home study in all sites, regardless of the product they used, reported some increase in appetite or weight gain in their child. ‘Before I bought my daughter boule [millet‐based porridge] for 25 CFA [US$0.06 at the time of the study] for the whole day, but with the use of Sprinkles^® she eats boule for 50 CFA [US$0.12] a day’ (Mother in Goudel, 4‐week study).

Many mothers reported that the weight gain in the child was noticed not only by themselves, but also by family and community members. Describing the weight gain of her daughter, one mother said, ‘At first when she was 5 months she weighed 3 kg. Then [my husband] did not pick her up because she was all lean. But now since she has gained weight he always picks her up’ (Mother in Gamkalley, 4‐week study). Mothers also reported that they noticed increased energy and strength in their children, and that their children were more likely to interact and play with other children.

Several mothers reported that at the start of the study, their child had darker stools and some mild diarrhoea. Most said that this did not worry them as they were told that this might happen. Some mothers felt that the diarrhoea was a sign that the products were working and that the body was getting rid of ‘bad blood’. Overall, the reported changes were perceived as very positive even though a few mothers were worried about where they would get enough food to satisfy their child's improved appetite.

Twice‐daily use

No mothers reported having any trouble remembering to give the products twice daily. All mothers with children enrolled in the home study understood either to give two sachets of Sprinkles^® per day or to split the sachet of Nutributter^® into two daily doses. The mothers did not like having to split a single sachet of Nutributter^® into two doses as they felt that it was difficult to correctly portion out half of the sachet, and they felt that it was unhygienic to leave the sachet open for the day. The mothers who gave their child Sprinkles^® twice a day were asked if they would prefer a single administration per day rather than two, independent of cost implications. Most mothers said that they would rather give two a day. Some commented that if the child wasted some food with the Sprinkles^® in it, they felt relieved that they would be able to give their child more Sprinkles^® later in the day. However, a few mothers felt that one sachet per day would be easier to remember.

Feeding practices

Many of the children enrolled in the 4‐week study ate boule (millet‐based porridge), and some also ate from the family dish. Many mothers also reported preparing special foods for their child such as bean soup, eggs, fritters, fruit and occasionally, pasta, rice and entrails. Nearly all mothers of children enrolled in the home study reported that their child already had their own bowl prior to the study and that they were generally fed from an individual bowl vs. the communal bowl. Few mothers had to buy or borrow any additional equipment to utilize either the Sprinkles^® or Nutributter^®; nine of the 59 participants (15%) that used Sprinkles^®, and three of the 56 participants (5%) that used Nutributter^® at some point in the 4‐week study said that they had to purchase something to be able to use the product. The items purchased included bowls, plastic cups, spoons and ladles. Mothers reported that bowls cost about 125 CFA (US$0.22), and spoons were about 50–75 CFA (US$0.09–US$0.13). All the mothers thought that this cost was acceptable and affordable for most families.

Observation of actual use of products

Nutributter^®

During the home study, 37 mothers who received Nutributter^® were observed in the household feeding their child. Most mothers opened the sachet using a razor blade, their teeth or scissors. Most children who were fed Nutributter^® directly were given it on a spoon, from their mothers' fingers or squeezed onto the child's hand. Most mothers gave the right amount of Nutributter^®; only one mother gave the child more than the instructed half of the sachet. One mother gave a little of the Nutributter^® to an older child who was asking for some. All children who ate the Nutributter^® mixed into food were given the food immediately after the Nutributter^® was mixed in. Of the 16 children who had Nutributter^® mixed into their food, four did not finish the food mixed with Nutributter^®. Only 2 of the 21 children eating it directly refused to finish all the Nutributter^®.

Sprinkles^®

Of the 38 mothers who were observed using Sprinkles^®, three children refused to eat their food mixed with Sprinkles^®. Nearly all of the mothers used the Sprinkles^® correctly, mixing the whole sachet into a small quantity of food in bowl or cup and feeding it to the child immediately. In Soucoucoutane, one mother used a sachet of Sprinkles^® that was already opened; one mother prepared the Sprinkles^® with a very dirty spoon; and one mother used a very dirty cup. All of the children were fed the food immediately after the Sprinkles^® had been added.

Intention to use and reported use of Nutributter^®

At the beginning of the home study, mothers were asked how they intended to give Nutributter^® to their child. Most mothers said that they intended to mix it into boule or some other kind of food. Several mothers also said they would give it to their child directly because their child liked sweet foods. A few mothers said that they would try it both ways and see which way the child preferred.

Of 37 households with Nutributter^® available on the day of the observation visit, 21 children were given the Nutributter^® directly and 16 children had it mixed into their food. Of the 37 households, 18 children were between 6 and 12 months of age. Of those 18 children, 10 were given the product directly and eight had it mixed into their food. Four out of the 18 children did not finish their Nutributter^® or boule mixed with Nutributter^®.

The results from the interviews at different time points revealed that although most mothers had intended to mix the Nutributter^® into food, more mothers ended up giving the Nutributter^® directly. Several mothers reported that they started feeding the child Nutributter^® one way and then changed. The main reasons mothers gave for changing from direct feeding to mixed with food are as follows:

• • child refused the Nutributter^® directly; and
• • child could not eat it easily alone.

The main reasons for switching from mixed with food to direct feeding are as follows:

• • child refused boule with Nutributter^®;
• • child prefers to eat Nutributter^® directly;
• • child did not finish boule and Nutributter^® was wasted; and
• • it was easier for the mother to just give the Nutributter^® to the child to feed himself.

Sharing and pressure to share

During the course of the 4‐week study, several women experienced pressure to share either Nutributter^® or Sprinkles^®. Women in both sites in Doutchi seemed to experience more pressure than women in the two Niamey sites. Pressure to share was mainly from older children in the household and neighbours. In a few houses, the co‐spouse and other family members also pressured the mother to share. During the course of the observations, the field workers also witnessed several instances where women were pressured to share. Most women did not share and told those pressuring her that the sachets were counted and were for her child only. Overall, five of the 80 mothers reported giving product away to other people, this included both Sprinkles^® and Nutributter^®. In two households, some of the products were stolen from the household.

Product preferences

In the two Niamey sites, children enrolled in the 4‐week study were given a 2‐week supply of Sprinkles^® and a 2‐week supply of Nutributter^®. Irrespective of the order of receiving the products, the majority of mothers (27 out of 37, 73%) said that if they were given the opportunity to select a product to continue using, and if it was to be given for free as it was in the home study, they would select Nutributter^®. Ten mothers selected Sprinkles^®. Out of the 37 mothers who responded to the question on product preference, 15 had a child between 6 and 12 months of age. Of those 15 mothers, 13 preferred Nutributter^®, and two preferred Sprinkles^®. One mother said she would select Sprinkles^® because it was cheaper than Nutributter^®, the other said that she would select it because the child would not realize that it had been mixed into the family dish. The main reasons the participants in the two Niamey sites gave for preferring one product over another is presented in Table 5.

Table 5.

Among mothers who used both Sprinkles^® and Nutributter^® for 2 weeks each, these are the reasons the participants gave for preferring one product over the other

Primary reasons for selecting Nutributter®
Sweet taste that the child liked
Ability to either mix the product or use directly
Nutributter® worked better than Sprinkles®
The child can eat it by himself

Primary reasons for selecting Sprinkles®
There is no taste and can be mixed into the family food without the child knowing
Sprinkles® worked better than Nutributter®
Child refused Nutributter®

When asked which product they would buy if both products were available on the market, the majority of women still selected Nutributter^® (25 out of 37). However, two mothers who had said they preferred Nutributter^® said they would choose to buy Sprinkles^® because it is cheaper.

Willingness to pay

Nutributter^®

At the end of the home study, mothers were asked how much they would be willing to pay for a sachet of Nutributter^®. The reported median price mothers in Niamey were willing to spend was 100 CFA (US$0.22, range US$0.05–US$1.05), and 50 CFA (US$0.11, range US$0.02–US$0.63) in Doutchi. When asked if they thought that 35 CFA (US$0.08) was a reasonable price for a sachet of Nutributter^®, 54 out of 57 (95%) mothers who had used Nutributter^® said they would be willing to purchase Nutributter^® at that price.

Sprinkles^®

Mothers who used Sprinkles^® during the home study were asked how much they would be willing to pay for a sachet of Sprinkles^®. The median reported that the price in Niamey was 50 CFA (US$0.11, range US$0.050–US$1.05), and 25 CFA (US$0.06, range US$0.02–US$0.73) in Doutchi. When asked if they thought that 15 CFA (US$0.03) was a reasonable price for a sachet of Sprinkles^®, reminding them that it was recommended to use two sachets per day, 57 of 58 (98%) said they would be willing to purchase it at that price.

There was no marked difference between what people were willing to pay for either product after trying the product in the home study compared with just seeing a demonstration of the product during the focus group discussions. Most women said that they would either ask their husbands for money to pay for the product or use their household money or the money they generated themselves from their small business. Women in Doutchi city said that they would use their own money to buy the products more often than women in the other sites.

Distribution locations

When asked where Sprinkles^® or Nutributter^® should be sold, a variety of answers were given. The primary places that people mentioned were pharmacies and health centres. Both of these were described as places that could be trusted not to sell expired products, and where the products would be protected from heat and dust. Additionally, pharmacies were described as places where set prices could be counted on; and health centres are where mothers are used to receiving counselling about child feeding and nutrition. Stores and street vendors appealed to some because they are prolific, and even young children could be sent with money to purchase the product. Larger stores were also described as appealing because they were protected from the elements. A few participants suggested having the chief of the area or village sell the products as he is a respected authority figure, and everyone knows where he lives and could go for more products.

Most people said that they would be willing to travel up to 5 km to buy either Nutributter^® or Sprinkles^® but that it would be difficult to travel more than 5 km on foot. People who could afford to take taxi motorbikes were prepared to travel much further (15–20 km).

Discussion

Overall, most participants in the focus group discussions and 4‐week home study were enthusiastic about both Sprinkles^® and Nutributter^®. Several other studies have also found Sprinkles^® to be acceptable to parents and children (Christofides et al. 2006; Adu‐Afarwuah et al. 2008; Jefferds et al. 2010), with less data available for Nutributter^® as it is a newer product (Adu‐Afarwuah et al. 2010; Hess et al. 2010). In the present study, mothers using the products were particularly pleased with the improvements they saw in their children's health. For both products, almost all mothers perceived that their child had an increased appetite and had gained weight, and many also commented on their child's increased energy and activity. A few mothers were concerned with how they would be able to provide for their child's increased appetite. However, overall, these changes in appetite were considered very positive. Similar concerns with increased appetite have been reported during formative research for a market‐based Sprinkles^® intervention in Western Kenya, where increases in household food costs due to increased appetite turned ‘a positive and valued effect into a potential problem’ (Jefferds et al. 2010). However, after 8 months of implementing the Sprinkles^® study in Western Kenya, monitoring data showed that this was not a widespread problem as only 5% of mothers reported that increased appetite was a barrier to Sprinkles^® use (Jefferds et al. 2009).

The results from this formative work suggest that even though this Nigerian population is very poor, some people are willing to buy products like Nutributter^® and Sprinkles^® for their children. Dewey found similar results in a study comparing three fortified products in Ghana (Dewey et al. 2009), suggesting that in some populations, people would be willing to purchase small quantities of products needed for in‐home fortification. One possible weakness of this study is that the participants were informed about some of the potential benefits of the products, including increases in appetite and activity, and a reduction of vitamin and mineral deficiencies, and this may have affected some people's perceptions about the products and their willingness to pay. Despite this, it was felt necessary to provide some general information on their use so that participants would not fear using the products or think that the products were being tested on them.

Most families across all four sites reported that they would be able to afford to buy Nutributter^® at a cost of ~US$0.08 or Sprinkles^® at a cost of ~US$0.03 several times a week. Families in Soucoucoutane, the most rural site included in the study, were also willing to buy the products. However, when asked how much they would be prepared to pay on a daily basis, they tended to propose a unit price that was lower than those proposed in the other sites and said that they would purchase the product when they were able to, but that they did not always have extra money. Soucoucoutane is a more rural and food‐insecure part of Niger and resembles the majority of the country more closely than Niamey. If a market‐based system was to be established, prices may need to be subsidized for the poorest families or for people living in the poorest areas, as it is unlikely that the most vulnerable could purchase the products at full cost, especially once overheads and marketing costs are built into the price. The base price of Sprinkles^® (depending on manufacturer) is about US$0.03 per sachet, and the price for Nutributter^® is about US$0.08 per sachet. With overheads built in, the price is likely to double. Furthermore, if it is determined that children should take two sachets a day to maximize the amount of iron a child can consume in a day, without delivering more iron than fortified complementary foods, the cost could be even more.

Another concern is whether the use of MNP or LNS products containing lower doses of iron would be efficacious if only purchased a few times a week. In Bangladesh, a flexible administration of Sprinkles^® led to better adherence and higher anaemia cure rates compared with daily administration (Ip et al. 2009). In a market‐based system in Kenya, purchasing and consuming Sprinkles^® about once per week was related to anaemia reductions in children (Suchdev et al. 2009). However, in both of these studies, the MNP used contained 12 mg of iron vs. the 6 mg used in this formative work. It is not certain that the efficacy of flexible administration would be replicated if lower‐dose iron content MNP and LNS are used. Currently, there are several ongoing studies looking at the efficacy of lower doses of iron in products such as MNP. Depending on the results from these studies and the ongoing systematic review of the association between iron intake and mortality in malaria‐endemic areas, recommendations for future programs using MNP and LNS could change substantially. Additionally, it should be noted that while this study explored two potential home fortification products, there are a variety of other fortification products available that were not included in this assessment. The selection of these products was purposeful but should not imply that these products are superior to others available, or that they are the most appropriate for this setting.

Despite concerns that many families would not be able to afford these products, even at a very low cost, our interviews and home visits show that most families are already used to buying special foods for their young children, such as yogurt, eggs, bean fritters, oranges and candies. While Sprinkles^® is a powder that must be added to other food, Nutributter^® is a sweet peanut‐based spread that can either be mixed into food or that children can eat separately and could be similarly categorized as some of the sweet items already being purchased for children. It is not clear if Nutributter^® was available for purchase, whether it would be bought in addition to or instead of these special foods, or which special foods the Nutributter^® might displace. Further work is needed to address these issues adequately. The considerable concern for children's nutritional status and corresponding health, combined with the fact that families already regularly buy special foods for young children, suggests that it is likely that many families would be willing to purchase Sprinkles^® or Nutributter^® for their children if the products were available in the community. However, although the results from this formative work suggest that families would be willing to pay for these products on a frequent basis, there is no certainty as to what extent willingness to pay will translate into actual purchasing behaviour. Research is limited in this area in relation to nutritional products, but there have been several studies that have looked at hypothetical and actual willingness to pay for health‐related products such as insecticide‐treated bednets (ITNs) (Onwujekwe et al. 2001). The results from Onwujekwe's study in Nigeria found that 76% of people that were hypothetically willing to pay for ITNs actually purchased them. Factors such as the number of people living in the household, sex and annual expenditure on gifts affected people's actual willingness to pay. Prior exposure to free ITNs was negatively associated with actual willingness to pay. Further work would be necessary in Niger to determine actual purchasing behaviour and to be able to determine the optimal price to charge for the products or the level of subsidy to include.

Other studies in Niger on people's willingness to pay for health‐related products, such as condoms and water purification, have found that a major barrier, affecting not only the price but the availability of the products, is the lack of a well‐developed system for delivering products. Since 2003, the German Development Corporation (GTZ) has been promoting the use of condoms through Animas‐Sutura using a social marketing approach. While they have found that people are willing to purchase condoms at around U$0.05 per condom, a major barrier has been distribution (German Development Corporation 2009). This problem has also been encountered by Société de Transformation Alimentaire ⁵ , who has been producing and selling a micronutrient‐fortified cocoa and milk‐based product called GrandiBien^® since 2007 (Fernandez et al. 2009). GrandiBien^® has been successfully marketed and distributed in Niamey, and formative research has demonstrated that mothers value the product and are aware of its beneficial effects on children and regularly purchase it. However, scaling up the approach to more rural areas of the country has been challenging. Even if the distribution system is made as efficient as possible, the population is scattered over a very large territory and costs will be higher than in more populous and urbanized settings. The results from this analysis suggest that in addition to transporting the products into rural areas, other factors such as product quality (including expiration and protective packaging), credibility of the vendor and protection of the distribution site from environmental conditions may affect willingness to purchase.

Both products were well liked, but mothers generally preferred Nutributter^® to Sprinkles^®. Although Nutributter^® was preferred, many people disliked splitting the sachet, and a single sachet would be advisable in the future. Despite concerns that asking mothers to give the product twice a day would be burdensome or reduce adherence, most mothers had no difficulties giving the products to their children twice a day.

Most people said that they would prefer to buy these products in pharmacies or health centres, as the products will be better protected and are less likely to be expired, and prices will be fixed. The main problem with selling the products in pharmacies is that pharmacies are less common in rural areas. Selling the products in health centres may also be problematic as the health care system in Niger provides free health care for children less than 5 years of age, and mothers would expect products given to their children to be free. If these products were to be sold in Niger, it is likely that they would have to be sold from a variety of locations that both ensured the quality of the product as well as the accessibility to remote populations.

Limitations of this analysis include that data were only collected in two main areas of Niger that may not necessarily be representative of other parts of the country, particularly more food‐insecure areas. Data were collected, transcribed and analysed in four different languages, and it is possible that some intention or meaning was lost in some places. Additionally, social desirability may have influenced participants' responses. This analysis also has multiple strengths. We used rigorous methodology including training and piloting to test the interview guides and standardize the research assistants, back translations of guides and multiple reviews of notes. Data were collected in different areas of rural and urban Niger from multiple types of informants, including mothers, fathers and grandmothers. Finally, all of this extensive formative work was done to aid in the development of a programme. Often, programmes do minimal or no formative work to understand the local context.

This study did not assess specific breastfeeding or complementary feeding behaviours during the 4‐week home study and is thus unable to determine how these behaviours may have been impacted by the intervention. It is important that any future programme carefully monitor usage of the products, including that children of the appropriate age are using the product and that the product is not interfering with other recommended feeding behaviours. While the intention of this formative work was to develop a market‐based distribution system, promotional materials should still include messages and other strategies to support good hygiene practices and recommended infant feeding behaviours, including how these products should be a part of a broader breastfeeding and complementary feeding context.

The findings from this formative work suggest that either Nutributter^® or Sprinkles^® would be well accepted but that overall, Nutributter^® would be the preferred product, even though it is more expensive. To ensure that the most vulnerable populations have access to the products, it may still be advisable to consider using these products on a larger scale, possibly using a mix of distribution mechanisms that may include free, subsidized and/or market‐based distribution given that (1) nutritional deficiencies between 6 and 23 months lead to irreversible damage; (2) MNP and LNS can effectively address some of these deficiencies; and (3) these products are acceptable. Further work is needed to determine what distribution system(s) could be used, especially in the more rural and inaccessible areas of the country. Working with other social marketing programmes already established in Niger could provide an excellent opportunity to market nutritional products such as these alongside other health‐related products. Any system promoting the use of products such as Sprinkles^® or Nutributter^® should be integrated into a comprehensive infant and young child nutrition strategy to ensure that breastfeeding and other complementary feeding interventions are supported.

Conflicts of interest

The authors have no financial relationships or conflicts of interest to disclose.