Preventing micronutrient deficiencies in children through their porridge
How a market-based, demand-driven porridge condiment can reach children at scale, starting in Kenya
Giselle’s kitchen is a tidy corner of her narrow balcony at the back of the room she and her husband share with their toddler. She doesn’t use much storage space because she can only afford to buy what her family eats for the day. Meat is rare in her diet. They alternate between tea and porridge for breakfast. She showed us how she makes her porridge. As the packaged sorghum flour mixed with water and thickened in the pot, Giselle’s son looked up at us from under his lashes with a cheeky smile. Sugar is expensive compared to porridge flour, yet towards the end of the cooking, Giselle added an amount almost equal to the flour she had used: “If I don’t have sugar, I won’t make the porridge.” This porridge will sustain her son in the morning and as an afternoon snack.
Millions of families around the world can’t feed their children enough nutritious foods, like fruits, vegetables, and packaged fortified foods. Because of this, it is estimated that worldwide, 340 million children under the age of five suffer from micronutrient deficiencies, a hidden form of malnutrition. Micronutrient deficiencies can interfere with children’s growth and development and lead to disabilities like blindness. 12% of deaths in children under five years old are attributable to the four most common micronutrient deficiencies: vitamin A, zinc, iron, or iodine.
A market-based demand-driven solution
Our design team — which included expertise in behavioral science, strategy, human-centered design, and public health — traveled to Kenya to understand the viability of delivering micronutrients to children in a new way. Our idea was to create a market-based, demand-driven product that could be purchased for a reasonable price at a kiosk or shop and deliver 2–3 doses of multi-micronutrients per week to children under 5. Taking it to market would overcome some of the major challenges with current micronutrient solutions including: supply chain, usability, and accessibility. Our aim is to partner with a company with the food development expertise to create the product and existing market presence to get it to market and used at scale.
Our initial vision of the micronutrient condiment was inspired by bouillon cubes that can be found in last-mile markets all over the world. The market penetration of bouillon and its daily consumption were characteristics we wanted to mimic. To ensure micronutrients in our product are taken up by young children, however, we knew our product needed to be targeted at the food they most commonly eat: porridge. The type of flavors, the form, and positioning of our micronutrient condiment remained open questions for the design research we conducted in Kenya.
“By working with an existing consumer goods company with high market penetration, we anticipate that within 5 years, we could reach 4.7 million Kenyan children under the age of 15 and 1.6 million under the age of 5.”
Current approaches to treating micronutrient deficiencies fall short
While a good diet is the ideal way for children to get the micronutrients they need, even in developed countries this is difficult to achieve without the fortification of packaged foods, like cereals, baby food, milk, yogurt, and orange juice for children. Vulnerable families lack the access to the wide range of nutritious foods children need because it’s not sold near them, or they simply cannot afford it. And while fortification of staple foods with iron and Vitamin A is becoming more common, this approach doesn’t address the specific and diverse micronutrient needs of young children.
The current solution is for governments and NGOs to distribute single-dose sachets of micronutrient powder that caregivers sprinkle on their children’s food, usually porridge, at room temperature. But micronutrient powder reaches fewer than five percent of children in need. Sprinkling a powder on already cooked foods just isn’t intuitive for caregivers and there is no immediate, perceptible reward for using the product — either in taste or visible changes in the child — which means that it’s often misunderstood. In one refugee camp in Kenya where micronutrient powder sachets were being distributed, people misunderstood it as a contraceptive. Because it’s not intuitive or something people would typically seek out, encouraging its use requires ongoing awareness and educational campaigns for caregivers. Furthermore, micronutrient powder sachets are often unavailable in health centers and retailers because they’re dependent on inconsistent public sector supply chains. Since there is little demand for the product, commodities can expire before they can be distributed. While we were visiting Kenya, we found that all the sachets in-country were expired.
These challenges are well-known by nutrition experts and health providers, but there are few alternatives that solve for the limited availability and desirability of the product. Families will be motivated to buy and use a product that appeals to caregivers and is demanded by children. Making this product available through private sector supply chains that reach the local kiosks where people shop every day is the best way to ensure consistent access and uptake at scale.
What caregivers want
We are encouraged by studies that have shown that caregivers are interested in investing in nutritious products, though willingness-to-pay for existing products vary for the same product across countries. A 2018 willingness-to-pay study in Tanzania found that 66% of mothers were willing to pay $0.68 USD per sachet of micronutrient powder. These studies support our own anecdotal work: During the ideation phase for malnutrition prevention in 2017, the IRC team set up a table at a market on the border between Liberia and Guinea to introduce unbranded micronutrient powder sachets, and caregivers flocked to the table, demanding to know where they could purchase the product. None of the dozens of caregivers seemed concerned about price. Unsurprisingly, taste has been found to be directly related to demand for nutritional products. A study from 2011 found that taste was a determinant of willingness-to-pay in fortified staple foods.
The IRC’s well-connected livelihoods team in Nairobi and the nutrition team in Lodwar in Turkana county, Kenya joined us in spending hours in the kitchens of Kenyans, Burundian, and Somali families, observing cooking practices with bouillon and porridge preparation. This work helped us to better understand caregivers’ needs, desires, and expectations.
“While porridge compositions differ across households, the preparation of porridge was consistent across income levels and cultural backgrounds.”
Sweetening porridge with nutrition
While speaking to caregivers, we learned that in addition to porridge being one of the first foods children eat, it continues to be eaten as a morning meal and afternoon snack, sometimes into early adolescence and even adulthood. This makes a micronutrient condiment for porridge a good way to target children.
While porridge compositions differ across households, the preparation of porridge was consistent across income levels and cultural backgrounds. For instance, porridge is made in a pot in the morning for multiple mouths, which means our product needs to be portioned for the pot, rather than for an individual child. Flavorings are added at the end of the cooking process, such as salt, sugar, and Blue Band fortified margarine. This is a window of opportunity for our product, but it also brought in a new design challenge: our micronutrient composition will have to remain stable under high cooking temperatures.
Caregivers are willing to try new, healthy products for their children, but unless it tastes good, they will not continue to purchase them. One caregiver we visited told us she recently saw a healthy porridge mix advertised on the streets and some of her neighbors were using it. She was willing to try it out, but her family preferred the taste of their usual porridge so she never bought it again.
We created packaging prototypes of our product using familiar brands and with different positioning. We then went into homes and to kiosks to get feedback on them from caregivers, customers at kiosks, and kiosk owners. We observed that brand association didn’t seem to have a positive effect, except for the bouillon brand, which was negatively associated with a healthy product, further validating the advice we received from experts and caregivers. The most appealing brand positioning was the “milk and honey” flavor (except in rural Turkana, where honey was not common) and the images with fruits and vegetables. Specific health attributes were not solicited by customers. We also learned that sachets are a better product form than cubes because they allow for multiple doses in one unit and the packaging has more surface area for communicating with customers.
This led us to believe that flavor was key to creating a condiment for porridge with an attribute that both caregivers and children want. Our product will be an alternative to the salt, sugar, and other ingredients caregivers currently use to flavor their porridge and will have the added advantage of being healthy for their children.
Our initial work will be informed by Kenyan context and markets, but given how ubiquitous porridge is across income levels and cultures, this product has broad relevance across global markets. By working with an existing consumer goods company with high market penetration, we anticipate that within 5 years, we could reach 4.7 million Kenyan children under the age of 15 and 1.6 million under the age of 5.
Speaking to caregivers like Giselle got us a little bit closer to understanding what characteristics of a market-based, demand-driven approach would be appealing to caregivers and their children. Now that we have a more refined version of our concept, we will work to ensure the product can be distributed where people want to find it and at a price that they can afford at a frequency that is most likely to result in health impact for their children.
Our next step is to identify a strong collaborating company with the ability to develop the micronutrient-infused product for palatability and stability; and the infrastructure and market insights to promote uptake of the product at a scale to substantively change the health status of a generation of Kenyan children.
