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Part one: The protocol

I. Context
II. Steps in the protocol

I. Context

A. The primary and secondary questions addressed by the protocol
B. Overview of design and timing

In this section we describe the research questions and the overview of design and timing required to conduct the protocol.

A. The primary and secondary questions addressed by the protocol

1. What are the key foods (staples, fruits, vegetables, animal food, fats/oils)?
2. What are cultural beliefs about key foods?
3. What are patterns of food use?
4. How is food prepared and stored?
5. What are the signs and symptoms of vitamin A deficiency?
6. Are there other important issues?

Fundamental to any successful effort at helping communities to overcome nutritional problems is understanding community conditions and cultural perspectives, particularly with regard to food use. Healthcare workers, nutrition educators, and nutrition researchers have encountered certain recurring features or themes that combine to produce nutritional deficiencies under conditions of restricted food supplies and inadequate medical care. The questions given below reflect those issues and problems that have been repeatedly identified as influencing nutrient consumption. There are six areas of primary questions, each with their secondary questions. These form the basis of the procedures within the protocol.

Answering these questions provides the data base from which nutrition planners, educators, and community people can work together to develop culturally-appropriate interventions to improve vitamin A status.

The research questions addressed are:

1. What are the key foods (staples, fruits, vegetables, animal food, fats/oils)?

i. How is food acquired in this particular locality or region? What food is purchased, traded, homegrown, or collected from the wild? In what settings are food items purchased? What food is grown locally or brought in from other areas?
ii. Are there periodic markets in the area? If so, when are the market days? What food is available in the markets? Where, and at what distance do people buy food outside the community? To what extent do people rely on the markets for food? Are there door-to-door vendors? For vitamin A-rich food?
iii. What are the non-animal sources of vitamin A-rich food available in the region? Are they seasonal? How much do they cost? Are they affordable?
iv. Do people have home gardens? If so, what food is grown in the gardens? What are the seasons for garden crops? Are the crops from home gardens mostly sold, traded, or consumed by the family?
v. Do people grow green leafy vegetables among their staple food crops? When and for how long are they available? Fresh or preserved?
vi. Do people gather food from the wild? If so, what plants or animals and how often? What people are involved?
vii. Are there available vitamin A-rich food items that are not eaten? If so, what are they and why are they not used?
viii. What are the animal sources of vitamin A-rich food available in the region? Are they seasonal? Are they affordable?

2. What are cultural beliefs about key foods?

i. What are the main qualities or attributes people recognize concerning their food? (e.g., tasty, strength-giving, filling, healthful, expensive, prestigious). Do these judgments about food vary according to age, gender, or ethnic subgroup?
ii. Have people heard of the term "vitamin"? What are their beliefs concerning vitamins?
iii. How are the foods rich in vitamin A perceived?
iv. What are the general ideas about suitability of various foods for children?

3. What are patterns of food use?

a. Pregnant women

i. What do women of childbearing age typically eat? Do they modify their diets during pregnancy? Do women recognize that their nutritional needs are greater when pregnant? Is there food associated with pregnancy?
ii. What vitamin A-rich food items are consumed by women? How often are they consumed and in what quantities?
iii. Do women perceive a link between food intake and pregnancy outcome?
iv. Are there food items associated with a difficult pregnancy?
v. Are there specific food practices (restrictions or preferences) during pregnancy?

b. Lactating women

i. What food is particularly consumed during the immediate postpartum period? Are there any food items which are believed to facilitate lactation?
ii. What do lactating women typically eat? What vitamin A-rich food is consumed? How often are these food items consumed and in what quantity?
iii. Do mothers recognize a need to eat more while they are breastfeeding? Is there any food associated with increased breastmilk?
iv. Are there perceived effects of vitamin A-rich food on the nursing child? If so, does this affect intake of food rich in vitamin A?
v. Are there food practices (restrictions or preferences) pertaining to lactating women? If so, to what extent are they observed?

c. Infants

i. When does breastfeeding begin? Is colostrum fed to the infant? Are there any postnatal ceremonies which interrupt the introduction of breastmilk?
ii. Are infants exclusively breastfed? If so, to what age? If not, why not?
iii. When is supplementary food introduced into the infant's diet? At what age are foods rich in vitamin A introduced? In what form are they given?
iv. What vitamin A-rich food items are introduced during the first year? At what stages are they introduced and in what form? How often does the infant eat this food and in what quantities are they served?
v. Do people have doubts or worries about the digestibility of vitamin A-rich food? Regarding digestibility of oil?
vi. Is the infant breastfed on demand? If so, to what age? Are there any other forms of milk fed to the infant during the first year of life?
vii. What factors, including cultural beliefs, affect the timing of cessation of breastfeeding?

d. Children one to six years old

i. What vitamin A-rich food is fed to children? How often are they fed these items and in what amounts?
ii. How often are children fed? Does the child follow the family's eating schedule? At what age are the children fed "adult food"? What is adult food?
iii. Are young children encouraged to eat? Verbally or by direct feeding?
iv. Is snack food available between meals? Are any of the snack foods vitamin A-rich? Are they seasonal or available all year round? What food items that are available locally do children select to eat?
v. At what ages are children thought to be able to digest the various vitamin A-rich fruits and vegetables?
vi. Are there differences in what male and female children eat? What are they and why?

4. How is food prepared and stored?

i. How are the various vitamin A-rich foods prepared? Are they boiled; fried? For how long? Are vegetables prepared with spices?
ii. What food preservation techniques are practiced? Are fruits and vegetables dried? If so, are they dried in sun or shade?

5. What are the signs and symptoms of vitamin A deficiency?

This set of questions concerns local cultural beliefs and practices concerning the recognition and interpretation of signs and symptoms of vitamin A deficiency. It is essential to use the photos on the inside cover of this manual when interviewing about eye signs. (see Glossary, Appendix 13) for definitions.

i. Is there a local term for nigh/blindness?
ii. Do mothers and other caretakers recognize nigh/blindness in infants? In children ages one to three years? In children ages four to six years?
iii. Do mothers consider nightblindness in infants serious enough to seek care? In children ages one to three years? In children ages four to six years? In themselves?
iv. Is nigh/blindness treated? If so, how? What home-based treatments and ways of management are used? Is treatment sought outside the home? If so, from whom? What kinds of health providers or practitioners are considered appropriate for treatment? What forms of treatment do they provide?
v. Do women of reproductive age experience nigh/blindness? If so, at what stage of pregnancy?
Do they perceive nigh/blindness as a problem or a symptom of pregnancy?
vi. Do women suffering from nightblindness seek treatment? If so, from whom and in what form? vii. Is there a local term for Bitot's spots?
viii. Do mothers and other caretakers recognize Bitot's spots? If so, are Bitot's spots recognized in infants? In children ages one to three years? In children ages four to six years?
ix. Do mothers consider Bitot's spots in infants to be serious enough to seek care? In children ages one to three years? In children ages four to six years? Is there a sign that prompts care-seeking?
x. What are the local cultural beliefs concerning the causes of Bitot's spots? Are there home-based treatments for this condition? Is treatment sought outside the home? If so, from whom? What kind of treatment?
xi. Is there a local word for corneal xerosis?
xii. How do mothers and other caretakers perceive corneal xerosis? What is done when an infant's cornea is apparently dry? When a child one to three years old has a dry cornea? A child four to six years?
xiii. Does corneal xerosis in infants prompt care-seeking? In children one to three years? In children four to six years? Is there a particular sign which prompts care-seeking?
xiv. What are the local cultural beliefs concerning causes of corneal xerosis? How is corneal xerosis treated in the home? Is treatment sought elsewhere? If so, from whom? What kind of treatment?
xv. Are there local terms for corneal ulceration, keratomalacia or xerophthalmia?
xvi. How do mothers and other caretakers perceive corneal ulceration or keratomalacia? What is done when these advanced stages of xerophthalmia occur in infants? In children one to three years? In children four to six years?
xvii. When scarring on the cornea or softening of the eye is apparent, is care sought? In infants? In children one to three years? Children four to six years?
xviii. What are the causes of corneal ulceration in the local cultural belief system(s)? Is it treated in the home? If so, how? Is treatment sought outside of the home? If so, from whom? What treatments are given?
xix. Do mothers and caretakers see xerophthalmia as a progression of eye-related problems? If so, how is that progression or sequence conceptualized?
xx. Are mothers aware of how quickly the various stages of nutritional blindness progress?
xxi. Do mothers recognize conjunctivitis? Do they consider conjunctivitis to be a serious condition?
xxii. Is conjunctivitis treated in the home? If so, how is it treated? Is care sought outside of the home for a child with conjunctivitis? If so, from whom? How is it treated?
xxiii. What other eye diseases do they consider serious and seek care for?
xxiv. Do mothers or caretakers associate eye problems with measles? With rashes? With diarrhea or worms? With respiratory infection? What explanations are given concerning these connections?
xxv. Do mothers or caretakers associate eye problems with food or diet? If so, how?

6. Are there other important issues?

i. Do women generally work outside the immediate household? If so, what do they do? How soon after childbirth do they resume full working schedules? Do they take the infant with them when they go to work? What is the extent of work women do within the family home or farm? How does women's work affect home food/garden production?
ii. To what extent are there general intracommunity variations in food use patterns due to culture, economics, etc.?
iii. What changes occur in women's work patterns during pregnancy? Does someone assist with the daily work?
iv. How is food distributed during mealtime? Does the entire family share one central plate? Do the males eat separately? How are vitamin A-rich food items distributed in the family?
v. Who controls buying food? How are food selections made? Who controls the finances?
vi. Are there infections common to the community?
Which ones? Measles? Respiratory disease? Intestinal parasites/worms? Diarrhea?
vii. What previous exposure have mothers had to health and nutrition education in this community?

B. Overview of design and timing

The manual is intended to provide nutrition program managers with useful information collected by field investigators with experience in qualitative research methods and food/nutrition evaluation. It is assumed that the investigators will be generally familiar with the cultural setting and language in the area in which the research is conducted, but that they may not be conversant with the techniques of formal ethnographic methods. Therefore, research techniques and procedures are presented here in detail.

The research is based on various types of data collection activities:

• Review of existing literature and reports on the historical, ecological, and cultural settings for community food use.
• Review of existing data on food composition for food items in the community food system.
• Market surveys for availability and prices of food.
• In-depth interviews with six to eight key-informants m the community.
• Structured interviews with a sample of twenty-five to thirty respondents (particularly mothers) interviewed in their homes.

Data are collected from a defined area that can be identified as a community. The reasons for conducting the study in a specific community, rather than across a broad geographic area, include the following:

a. Qualitative ethnography aims to identify and describe behavior patterns and shared beliefs. In most of the world, the minimal social-geographic unit of shared culture is the community. Beyond the community, patterns become more difficult to identify because of linguistic and ethnic variation and differences in community resources and characteristics.
b. Food availability may vary significantly from one community to another depending on its location and access to water.
c. Healthcare providers are typically organized at the community level. A researcher investigating care seeking practices can obtain information about local health providers relatively quickly on a community basis.
d. When assessment team members can reside in the location where they are conducting the study they have greater opportunities to observe local practices and behaviors and therefore can obtain greater insights regarding local conditions than can a researcher who quickly moves from one community to another.

The study is designed to be conducted in a period of six to eight weeks, including the data analysis and preparation of the report. Completing the study in this short time period will require the full-time participation of a team leader with two field assistants. Depending upon the situation, a translator may also be necessary. The study involves the use of both qualitative and quantitative research methods. Ethnography can identify household food practices and perceptions about both vitamin A and staple foods that can suggest ways to construct messages to encourage the consumption of vitamin A-rich food items. The information collected can also be used to delineate patterns of health seeking care for the treatment of xerophthalmia and improve communications geared to prevent and control nutritional blindness.

In order to communicate effectively, health workers need to understand beliefs and practices surrounding the consumption of vitamin A-rich and staple food. They will also need to know local terminology regarding the stages of xerophthalmia and expectations for treatment. Ethnographic data can be used for the development of training materials for health workers and nutrition educators.

Ethnographic research is designed to gather data to develop appropriate and effective messages that health workers can use to communicate to mothers and other caretakers during face-to-face interactions in the community. The information collected from this study can be used to develop messages to reach all families in the study population.

Since the study is to be carried out over a period of six to eight weeks, or less, the data collected is not intended to cover all cultural-behavioral aspects of consumption of the food system, or of vitamin A-rich foods, or perceptions and explanations surrounding xerophthalmia.

Defining a Timetable

Since the research involves both qualitative and quantitative methods and includes different procedures and various kinds of data-gathering, it will be helpful to set a schedule to ensure that the research is completed within the designated time frame. How you determine the time necessary for each phase of the research will depend upon the level of expertise of your research assistants and the accessibility of the groups of respondents.

An example of a timetable to complete the entire protocol in a six to eight week period is shown in Figure 1.1.

FIGURE 1. 1 Protocol Timetable










Set-up and Background Data



Community Food System Data Tables









Key-Informant Interviews








Household Food List



Market Surveys





Mother-Respondent Interviews






Interpretation and Report



II. Steps in the protocol

A. Site selection
B. Historical, ecological, and cultural setting for the food system
C. Field activities
D. Preparing the assessment report

Although the time period for the study is short, it is useful for purposes of organization and planning to subdivide the assessment process into several phases:

1. Background, market survey, setup of food system data tables format.
2. Interviewing key-informants and creating family food lists, food system data tables.
3. Preparation for structured interviews: review of initial data from key-informant interviews; preparation and pretesting of structured interview schedule concerning diets, with special attention to food rich vitamin A.
4. Preparation for structured interviews: review of key informant data on cultural beliefs and practices concerning xerophthalmia; preparation and pretesting of structured interviews on the signs and symptoms of nutritional blindness.
5. Structured interviews with mother-respondents. These respondents are interviewed at least three times to complete the six modules.
6. Final market survey, data consolidation, and report writing.

A. Site selection

Site selection is critical when conducting vitamin A assessment. The following criteria should be followed when choosing a community to carry out the study:

• The community should be representative, both linguistically and ethnically, of a large block of the general population.
• The area of study should be one where significant rates of vitamin A deficiency are known to exist or are highly suspected, or an area in which morbidity and mortality from childhood diseases related to the deficiency (diarrhea, malnutrition, respiratory illnesses) are high.
• The area of study should be one in which a range of foods, including vitamin A-rich foods, are available and accessible.
• The area must be accessible by road, and telecommunications should be available.
• The area of study should have some formal health structure with staff that can introduce the project team to the community and provide logistical support.

See Appendix 1 for further discussion of the selection of research sites.

B. Historical, ecological, and cultural setting for the food system

An important part of the initial data-gathering is collecting the existing information on the factors and forces influencing the food system of the community selected. By this, we refer to all factors that make certain food items available to the local community setting to form the family food base. Included in this is a review of existing data on the nutritional status of this population, and especially with respect to vitamin A status. A checklist of this important information is given in Appendix 2.

The assessment manager should review documents in public and university libraries, and public offices in the health and agricultural sectors. This information may include published ethnographies of the culture(s) of the community or region, and histories and geographies of the region with special reference to land use, agriculture, and food supplies. Topographical maps of the area, climate data, crops grown, economic activities and usual income, agricultural extension activities to improve food supplies, census data, and other such information, are all important to define the setting of the food system. Reports on successful community development activities, including NGO activities in the area that emphasize food resources may give helpful clues for potential interventions.

An example of salient information reported for a study site where this manual was tested, for the Aetas of Canawan, Morong District, Philippines, is given in Appendix 2A.

A careful review of the vitamin A situation in the region is needed. Any published or unpublished reports that discuss nutritional deficiencies should be gathered together, especially those specific to vitamin A and illnesses related to vitamin A deficiency. This may include data on dietary intake, serum levels, or availability of vitamin A-rich foods, or infant and child morbidity and mortality data. Community assessment of natural food sources of vitamin A is particularly valuable in areas known for vitamin A deficiency.

A concise summary (five to ten pages) should be prepared, with background information which will assist in discussions with local government officials and in briefing the field team.

C. Field activities

1. Key-informant interviews
2. Family food lists and selecting the key foods
3. Market survey 1 and 2
4. Constructing food system data tables
5. Structured interviews with mother-respondents
6. Research modules

Once the field site has been selected, the personnel recruited and trained, and the facilities made available, data-gathering can begin.

To understand the community and the use of its food system, the manager and the field assistants gather data from general information sources, such as libraries and government reports, community markets, and key-informants (see Glossary, Appendix 13). Key-informants are individuals with whom the research team consult regularly throughout the research process.

Section II-5 describes data-gathering from mother respondents using a series of modules (exercises) which define more structured interviews to answer specific research questions. These respondents are usually interviewed at least twice to complete the five modules.

You will find it helpful to create a master list of interviews conducted, dates, key issues discussed, follow-up needed, and follow-up completed.

1. Key-informant interviews

Key-informant interviewing is an extremely powerful ethnographic research tool. Information gathered from in-depth interviews will provide the primary data to direct research operations. Data will be used to identify key vitamin A food sources in the community and for the explanation of local food use and food consumption, particularly as it pertains to children. The interviews will define the various components necessary to describe the food culture in the community, focusing on cultural beliefs as they relate to vitamin A-rich food. The team leader/manager will also obtain information that will allow him or her to explain the reasons for vitamin A deficiency in the community and to suggest plausible interventions.

Key-informants will provide necessary baseline information on cultural beliefs related to both vitamin A-rich and staple foods in order to carry out the structured interviews. Key-informant interviewing allows the researcher to formulate a general picture of the basic eating model in the community. Critical information on price, seasonality, and availability of food will be taken from both key-informants and mother respondents.

From the key-informants, the team leader/manager will also gather information to: understand household food acquisition, including foods that are purchased, gathered or grown; identify food distribution patterns at the household level and age-specific beliefs, together with practices that apply to sources of vitamin A foods; determine food preparation and preservation techniques; identify terms related to signs and symptoms of vitamin A deficiency and perceptions regarding these signs and symptoms; determine expectations concerning the progress of the signs and symptoms of vitamin A deficiency; identify less visible healthcare resources available in the community; identify treatments for vitamin A deficiency administered by the health providers; and determine the decision-making process in dealing with the illness. This information may also be useful to identify events held in the community when special foods are consumed.

Although key-informant interviewing is meant to be flexible, it is necessary to pursue certain goals during the interviews in a particular sequence. Tasks carried out with key-informants could take the following order:

First Interview

• Free-listing to generate a list of key vitamin A-rich and staple foods in the area.
• Gathering general information about aspects of the key vitamin A-rich and staple foods, such as price and seasonality.
• Getting a complete list of health resources in the area.

Second Interview

• Pretesting and evaluating procedures to use with mother-respondents.
• Building on general information about vitamin A and staple foods and related materials from previous interviews.

Remember that you will continue to interview key informants throughout the duration of the study to get detailed information on food perceptions, food consumption patterns, and health practices, and to substantiate data gathered with mother-respondents. Often it is more effective to have shorter, frequent sessions with key-informants, rather than meeting with them for long periods. Be sure to schedule interviews when it is convenient for the informants so that they are not pressed for time. Always keep in mind the reason for which key-informants were selected and try to tailor the interview according to each informant's particular background. The team leader/manager will want to vary the interview schedule with different informants.

Once you have completed the first interviews with key-informants, it will be necessary to consolidate the results. Key-informant interviews will be used to: 1) identify vitamin A-rich and key staple foods, and their associated attributes and classifications; 2) develop a preliminary explanatory model of xerophthalmia in the community; 3) identify local healthcare providers; and 4) pretest the interviews to be used for the structured interviews. Please read Section IV-A: "How to Select Key-Informants and Conduct Key-Informant Interviews" (pages 85-86).

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