Questionnaire findings
A total of 50 questionnaires were completed with 10 per village. The responses to questions 1 to 4 (Additional File 1) were used in the design of dietary data collection tools, and are not reported here.
In terms of maize flour type, 35 households (70%) were planning to consume woyera (refined flour), 14 (28%) were planning to consume granmill (partially-refined flour), 10 (20%) were planning to consume mgaiwa (whole meal flour) and zero households planning to consume madea (maize bran) in the following month. However, when participants were asked hypothetically which type of maize flour they would most like to receive as a gift, more selected granmill (52%) than woyera (36%). Potential reasons are explored in the FGD findings. Mgaiwa and madea were less popular.
Table 1. The type of maize flour participants would prefer to receive as a gift.
|
Mgaiwa
|
Granmill
|
Woyera
|
Madea
|
|
n (%)
|
1 (most preferred)
|
6 (12)
|
26 (52)
|
18 (36)
|
0 (0)
|
2
|
20 (40)
|
15 (30)
|
15 (30)
|
0 (0)
|
3
|
23 (46)
|
8 (16)
|
16 (32)
|
3 (6)
|
4 (least preferred)
|
1 (2)
|
1 (2)
|
1 (2)
|
47 (94)
|
In the questionnaire, 8 out of 50 participants reported eating nsima outside the household the previous day, of whom two reported it was at church gatherings while others did not report a special occasion. Five participants gave away flour and 6 participants received flour as a gift (Table 2).
The estimated amounts of flour given away or received as a gift ranged from <1 kg to >20 kg and 1 kg to >20 kg, respectively. Nevertheless, the questionnaire results also indicated that this exchange of flour was ~equally likely to occur with a household outside the village as within it. Similarly, for 3 out of 8 cases where meals were consumed outside the household, this occurred outside the village or at a restaurant. Thus, clustering at the village level would likely reduce but not completely avoid contamination.
Table 2. Among questionnaire participants (n=50), the number that consumed nsima outside the home, received a gift of maize flour or gave away maize flour on the previous day
|
Consumed nsima outside household
|
Received maize flour gift
|
Gave away maize flour
|
Did not occur
|
42
|
44
|
45
|
Occurred: with household in the village
|
5
|
3
|
2
|
Occurred: with household outside the village
|
2
|
3
|
3
|
Occurred: restaurant
|
1
|
0
|
0
|
No participants expected to receive free flour as part of any food distribution programme over the next 2-3 months.
The majority of participants stored their maize flour in sacks (n=39), while others reported using plastic buckets and cloths.
No participants reported using at-home fortification or taking micronutrient supplements. Only one participant reported use of micronutrient supplements (vitamin A, by a child aged 5-10 years).
Focus Group Discussions and Key Informant Interviews
Three FGDs were conducted with adult men and three FGDs with adult women. In addition, nine in-depth KIIs were completed. Following transcription of FGDs and KIIs, a code tree was developed and quotes were categorised (Table 3).
Table 3. Focus Group Discussion and Key Informant Interview Code Tree
Main category
|
General category
|
Sub-category
|
Flour consumption
|
Flour type preferences
|
|
|
Location of flour consumption
|
|
|
Sharing / gifting / selling maize flour
|
|
Intervention perception
|
Trust in actual maize meal content
|
Family planning tool
Benefits from the intervention
|
|
Trust in blood sampling
|
Actual purpose of blood sampling
Amount of blood sample
Who is going to draw blood samples and where
|
How recipients/participants are perceived by wider community
|
Jealousy
|
Name calling (Lazy)
Stigma
|
Community sensitisation
|
The need for sensitisation
|
|
|
The process of sensitisation
|
|
Flour consumption
The most appropriate type of flour to distribute was explored in FGDs and KIIs. Participants noted:
“It should be granmill because you can cook porridge as well.” (FGD F1)
“Granmill is okay because it will cater for all the meals.” (FGD F1)
The potential issue of households eating maize flour outside the home was also explored in the FGDs and KIIs. Participants suggested that eating at home as a family unit is most common:
“These days each family eats on their own.” (FGD M3)
“It’s rarely that we share with our neighbours.” (FGD F3)
“The eating of food from other houses cannot be much. Maybe not very often, it can be once or twice a month, it’s not every day…it is different from the past. In the past, women used to come together, several households come together with plates of food. But nowadays things are changing, so the owner of this house is supposed to eat in this house.” (KII, Agricultural extension worker)
Participants suggested that, if they were receiving maize flour as part of a trial, they could give their own flour instead of the study flour for special occasions such as weddings, funerals or church gatherings:
“We will get the flour from our fields that we have kept.” (FGD F1)
“We cannot share [the trial flour] because this will be specific for a purpose. Probably we can give the maize flour that we grow.” (FGD M1)
Several FGD participants raised the issue of guests, and that it would not be culturally appropriate to cook a different type of flour for guests:
“It is wrong to cook and eat for the family and prepare another for the visitor. The visitor will think we have poisoned the food. The visitor will not be comfortable to eat the nsima unless we eat together.” (FGD F2)
“…when we have the visitor, they will have to eat the same flour.” (FGD F1)
There was a risk that participants would simply sell the trial flour. However, the FGD participants noted:
“Selling things that you have been given it’s not good. We sell things that we have worked for.” (FGD M1)
“It’s better we sell what is ours, than what we are receiving because that may compromise the study.” (FGD F1)
The qualitative results supported the provision of maize flour rather than maize grain because maize flour is less likely to be sold than grain.
“…people here will be surprised to see you selling the flour. It’s in town where we see people selling flour.” (FGD M2)
“The only year when I saw people selling maize flour was the year when there was hunger the whole country. Then people were indeed selling maize flour. There’s no one who can bring maize flour on the market and expect people to buy.” (FGD M3)
However, distribution of flour rather than grain would not eliminate the risk of selling:
“It’s better off to give them flour unlike the actual grains, but still we should anticipate some maybe going that far of selling, because I have seen even some people selling the flour they have gotten from the hospital, the therapeutic flour for their child under the CMAM [Community Management of Acute Malnutrition] programme.” (KII, District-level Nutrition Officer)
“They [the men who sell flour] put the flour in their trousers and when they get to the beer hall, they exchange with beer.” (FGD F3)
“Sometimes it is us women, we have a problem, if our neighbour has no maize flour and she has money, we steal from our house and sell the maize, while the husband is away.” (FGD F3)
“The maize flour we put in a bucket when we are going to draw water. Our husband thinks the bucket is empty yet there is maize flour which we are going to sell at the borehole to another woman.” (FGD F3)
Involving the village chiefs in the process would potentially reduce risk of selling flour:
“In our village it is not possible [to sell maize] because when we harvest, we are called by the chief who addresses us. He advises us not to sell the maize because, like this year we did not harvest well so he would tell us not to sell the maize and to care for the food. Because of that we do not sell.” (FGD F3)
Intervention perception
The key themes around the communities’ perception of the proposed intervention are summarised in Table 4.
Table 4: Cross Tabulation of Communities Perception of the intervention
|
Main category
|
Men
|
Women
|
Trust on actual maize meal content
|
***
|
***
|
Family planning tool
|
**
|
|
Benefits from the intervention
|
***
|
***
|
Trust in blood sampling
Evil/Satanic intentions
|
**
**
|
***
***
|
Amount of blood sample
|
***
|
*
|
HIV testing concerns
|
**
|
*
|
Recipients perception: Jealousy result in name calling (Lazy)
|
*
|
|
Stigma
|
*
|
**
|
(*) Number of FGDs in which participants mentioned the theme: 1 FGD = (*), 2 FGDs = (**) and 3 FGDs = (***)
Thus, similar concerns were raised by male-only and female-only FGDs, although the concern that the flour might be a covert family planning tool was raised only by male FGDs.
Focus Group Discussion findings revealed the participants had mixed perceptions of the proposed trial. Most community members perceived potential benefits and motivation of the intervention i.e., the receipt of free maize flour for 12 weeks.
“We will eat the trial maize flour because we don’t have adequate maize flour in our houses”. (FGD F2)
“They will give us free maize flour and we will know our nutritional status after blood test”. (FGD M1)
Similar observations were made by key informants:
“The motivation [to participate] is food. If you give them food, they will be happy. That’s the motivation.” (KII, Agricultural extension officer)
Participation in previous research also seemed to influence their perception of the proposed trial:
“Most of the farmers have positive experience with research because they know that after the research those things will be implemented for their own benefit, so they welcome that.” (KII, Agricultural extension officer)
On the other hand, some participants had reservations. The main areas of concern were: (i) lack of trust in what will be added to the AHHA trial maize or maize meal, (ii) fears over the blood sampling routine, and (iii) concerns regarding negative social stigma.
Community perceptions of blood sampling were critical, because blood samples would be required in the AHHA trial to assess the intervention’s impact on selenium status. Regarding blood sampling, some respondents felt that sampled blood might be used to assess the prevalence of HIV in the area, whereas others were concerned about the amount of blood that would be collected. One of the respondents said:
“How much blood will be collected? Won’t they test other diseases?” (FGD M1)
Another respondent said:
“We will provide blood samples once we know the required amount.” (FGD F2)
Other concerns related to whether the blood samples would be used for non-health related purposes. One of the respondents said:
“Maybe blood sampling has to do with Satanism.” (FGD F2)
Another participant said:
“Once the child is sick, many will say; you are in the camp of Satanist; they fed you well to become fat so that they can kill you.” (FGD F3)
On the other hand, most respondents indicated they were not concerned with the sampling of blood, as illustrated by the following quote:
“Blood sampling will not be a problem since you said you will only test nutrients in the blood.” (FGD M1)
Another respondent said:
“Blood sampling will not be a problem since small amount of blood will be sampled.” (FGD M3)
Community perceptions of the quality/safety of the flour and the researchers’ intent in providing trial flour is critical because participants and other household members must be happy to consume the allocated flour. One of the major obstacles noted by participants was trust in the trial flour.
“…people will relate to anything they receive to be not real things, they will think that it is sort of fake” (KII, District-level Nutrition Officer)
Some respondents felt the maize meal would be used as a family planning tool. In response to whether children would be allowed to eat the maize meal enriched with selenium, one respondent said:
“If the maize meal can make our children infertile then children will not be allowed to eat. But if it will make them healthy as indicated, then children will eat since they eat what parents eat.” (FGD M3)
The observation was also noted by key informants:
“…they might think you are involving them in family planning.” (KII, Health Surveillance Assistant)
Previous health-related programmes have identified similar issues when free items were distributed in the community:
“I will give you an example of the mosquito nets. So, government distributes mosquito nets to the people, and then the people say that these mosquito nets are there to make them…not to make them have babies…they affect fertility.” (KII, District-level Information Officer)
Micronutrient programmes in Kasungu District have faced similar challenges:
“People were saying just don’t go to the hospital because they have asked you to go…don’t just give your children vitamin A, which is aimed at making future generations impotent.” (District-level Nutrition Officer)
Despite these concerns, most respondents indicated that they would be willing to eat the maize meal provided if it was endorsed by government officials:
“Other people will eat the maize meal because they trust the recommendations by government.” (FGD F1)
“We can eat the maize meal because we feel it is good for us since the government has approved it.” (FGD F1)
Previous food distribution schemes caused upset in communities because so few households benefitted:
“There’s been an outcry of course, and I remember at one point in time, the chiefs could not even manage to allow the partner to distribute the food, just because it has come little compared to the number that is supposed to benefit from that.” (KII, NGO Nutrition Advisor)
When it was proposed that everyone will be receiving the flour, including the village chief, participants reported that this would likely reduce fear and suspicions:
“This is something very good because there will be no people complaining. If that is the case, then most people will be consuming the flour. Because they know that each and every one is consuming this flour. It’s not strange flour.” (KII, Agricultural Extension Officer)
The timing of the flour distribution was also discussed:
“If you change the months, maybe starting in the lean period, it will also be taken as relief food.” (KII, District Information Officer)
How recipients/participants are perceived by wider community
Concerns were raised about the social stigma associated with receiving free food. Some community members felt people outside the study area would stigmatise the beneficiaries (partly because of jealousy):
“Community members talk a lot about free food. Sometime back people received free maize; they nicknamed them as lazy people.” (FGD M1)
A similar observation was noted by key informants based on their experience of food distribution programmes:
“Of course, the ones who were not receiving [food distributions], they were maybe just jealous…so that’s why they were calling them ‘Manjalende’ [lazy people who can’t feed themselves].” (KII, District-level Nutrition Officer)
And:
“[Those who did not receive the food distribution] were calling them ‘Manjalende’, it’s like the people were just waiting for free food.” (KII, District-level Information Officer)
However, this concern was not universally shared:
“…the neighbouring village would be talking, saying ‘oh those people they are very lucky’… they cannot talk negatively, this is food. They would just admire. They can just appreciate that their friends are very lucky.” (KII, Health Surveillance Assistant)
Community sensitisation
The results of the formative research underscored the importance of community sensitisation. Good sensitisation – appropriate communication conducted by the right people – would be essential to overcome negative perceptions.
“…every new thing it’s received with some doubts. People talk because there’s no information. If people have information and have everything, it clears out those misconceptions.” (KII, District Information Office)
Sensitisation would be important to garner community support for the trial:
“The first thing is sensitisation. You can sensitise them, there after we shall be working hand-in-hand together with them.” (KII, School head teacher)
With good sensitisation, participants would be more likely to consume the flour:
“I don’t think rejecting [the flour] can happen, first of all there has to be strong community mobilisation, people they have to be sensitised fully, why that is being done.” (KII, District-level Nutrition Officer)
Sensitisation was important to address negative perceptions and fears related to blood sampling.
“They can’t raise issues if people can be sensitised before…They must know that our friends are going there for this, we were told about this, so that’s why these women are going over there.” (KII, Health Surveillance Assistant)
“…because blood sometimes can be a delicate thing in our African culture, but if they understand why you are doing that, I don’t think there can be a problem.” (KII, District-level Nutrition Officer)
Several key informants noted the importance of involving Health Surveillance Assistants in the sensitisation process. Their support was important to gain trust in blood collection:
“…people are [used to] giving blood samples to detect malaria. You know the Health Surveillance Assistants, they go and collect samples of blood… so the HSAs should be there to tell the people and answer their questions.” (KII, Agricultural Extension Officer)
The HSAs also provide an important point of contact with the communities, helping to direct sensitisation efforts and addressing particular concerns:
“The HSA is the one who works directly with the communities… I think the HSA is the first person who gets information from the household.” (KII, District-level Information Officer)
The other key individuals identified for the sensitisation process were those in positions of authority or influence:
“…the chiefs, they are also the ones who can help, because they respect them, so what the chiefs may say to the villagers, the villagers understand very well that our chief is supporting this.” (KII, District-level Nutrition Officer).
“The church has to be involved because a large number of people gather there, so it’s very easy to distribute the information.” (KII, Health Surveillance Assistant)
An important lesson from the gender segregated FGDs was that men, in this patrilocal society, placed more trust in their village headman whereas women placed more trust in the HSAs with whom they had frequent interactions through antenatal clinics.
“The message on feeding trials will be underrated (anthu akanyozera), if it is disseminated by the village headman alone.” (FGD F1)
Participants noted the importance of involving groups who can represent the community during the sensitisation process. The community care group volunteers were cited as an appropriate network:
“They [the community care group volunteers] are the first people I would use…to disseminate information.” (KII, Health Surveillance Assistant).