Formative

Research
Guidance
Introducing Multiple
Micronutrient Supplements (MMS)
2
Contents
04 Acknowledgments
05 Introduction
06 Step 1: Understanding the context
07 Step 2: Defining formative research objectives, methods, and tools

09 Ethnographic analysis: Semi-structured interviews

13 Ethnographic analysis: Free listing
15 Enthographic analysis: Pile sorting
17 Focus group discussions
19 Participatory workshops
23 Direct observations

25 Step 3: Using formative research to inform the design of an MMS

program/intervention
26 Step 4: Planning for formative research
28 Conclusion
28 References
30 Annexes
30 Semi-structured interview guide (pregnant women)
31 Semi-structured interview guide (health workers)
38 Pile sorting analytic framework

3
Acknowledgments

This guidance manual was prepared under the leader- team (Marie-Claude Desilets, Kumiko Takanashi) for the
ship of UNICEF Headquarters (New York, USA), Sight in-country technical support and coordination, as well
and Life Foundation (Basel, Switzerland), and The as the support and involvement of government officials.
Pennsylvania State University (University Park, USA).
This manual would not have been possible without the Tanzania: We would like to thank Esther Elisaria, Jack-
contributions from many individuals and institutions line Mrema, and Charles Festo from the Ifarkara Health
that collaborated to successfully conduct formative re- Institute for management of all in-country study pro-
search in four countries during 2020 – 2021 to inform cedures. Thank you to the UNICEF Tanzania team (Fa-
guidance manual development. toumata Lamakonde, Abraham Sanga, Kudakwashe Chi-
manya) for valuable technical support. Many thanks to
Bangladesh: The MMS formative research could not Mbeya authorities at all levels for fieldwork support, as
have been completed without the support of govern- well as Catholic Relief Services for safe transport.
ment officials representing the National Nutrition Ser-
vices, Institute of Public Health Nutrition (NNS-IPHN) Across study settings, technical and financial research
of the Directorate General of Health Services (DGHS), support was provided by team members from UNICEF
Ministry of Health and Family Welfare (MoHFW) during Headquarters (Nita Dalmiya, Nona Reuter), Sight and
fieldwork, as well as the members of the Technical Ad- Life (Madhavika Bajoria, Kesso van Zutphen, Rebecca
visory Group supporting provision of MMS through the Olson, Puja Tshering, Dr. Klaus Kraemer), The Penn-
antenatal care public health platform in Bangladesh. sylvania State University (Raphia Ngoutane, Ramak-
Importantly, we extend our sincere thank you to our wende Zoma, Akshata Yalvigi, Rachel Bruning, Katelyn
larger research teams at icddr,b including Anamika Kostakis, Suzie Simons, Rachel Siko, Stephen R. Kod-
Sarker, Ahsanul Kabir Likhon, Anita Sharmin Meem, ish). With special thanks to the Bill & Melinda Gates
Fatima Tuz Zahra, Maksuda Khanum, Mohammad Miea, Foundation who has provided financial and technical
Monisha Dey Eva, Samira Binta Amin, Shahadat Taraf- support through IMPROVING: Introducing Antenatal
der, Shakila Afrin, Syed Abdullah Al Mamun Apu, and Multiple Micronutrient Supplementation in Prioritized
Syead Tamim Mahmud. Countries (in Asia and Africa) (grant INV-007801 to
UNICEF).
Burkina Faso: We are most grateful for Dr. Cesaire T.
Ouedraogo who carried out the MMS formative research Finally, we are most grateful for the participation of the
fieldwork, data analysis, and interpretation of findings many pregnant and lactating women who graciously
in Burkina Faso. Additional technical support was pro- shared their pregnancy-related experiences, percep-
vided by UNICEF Burkina Faso (Mediatrice Kiburente, tions, and interests during fieldwork in Bangladesh,
Bertine Ouoro Dabire Dowrot) and the Directorate of Burkina Faso, Madagascar, and Tanzania. We hope
Family Health (Dr ZOMBRE/SANON Valérie Marcella, Dr that this guidance manual will be used to improve the
DADJOARI Moussa). health and nutrition of vulnerable populations in other
settings where MMS may be introduced globally.
Madagascar: We could not have completed this for-
mative study without the dedication of our local part- Suggested Citation: UNICEF, Sight and Life, and Penn State
ner, the GRET-Madagascar team (Andry Razakandrainy, University. 2022. Formative Research Guidance: Introducing
Jean-Michel Rakotoarivelo) who managed fieldwork Multiple Micronutrients Supplements (MMS). UNICEF and
activities during especially challenging circumstances. Sight and Life: Geneva, Switzerland.
We would also like to thank the UNICEF Madagascar

4
Introduction What is formative research?

This formative research guidance contains simplified Formative research is the process by which research-
guidance to assist countries to introduce multiple mi- ers or public health practitioners aim to understand the
cronutrient supplement (MMS) for pregnant women. characteristics (e.g., current behaviors, perceptions,
MMS is a unique formulation of vitamins and minerals needs) of target populations that influence their de-
for pregnant women and has been demonstrated to be cisions and actions. Formative research may be con-
safe, cost-effective, and improves maternal and child ducted prior to the design of a behavioral intervention
nutrition and health outcomes, including reducing the but also may be conducted during implementation, as
incidence of low birthweight (LBW) and small-for-ges- a type of process evaluation, for improving delivery or
tational age (SGA) when compared to iron folic acid course correction as needed (Evans, Scourfield, and
(IFA) supplementation (Bourassa et al., 2019). Murphy, 2015; Kodish et al., 2015). Typically, formative
research approaches utilize multiple mixed methods
The 2020 update to the WHO Antenatal Care Recom- (quantitative and qualitative) to triangulate findings
mendations for a Positive Pregnancy Experience rec- across different participant types and data sources
ommends the use of MMS containing iron and folic acid (Bentley et al., 2014).
in the context of, “implementation research to estab-
lish the impact of switching from IFA supplements to
MMS, including evaluation of acceptability, feasibility, Why is formative research important?
sustainability, equity, and cost-effectiveness” in each
setting, before introduction of MMS (World Health Or- Formative research examines the prospective target au-
ganization 2020). WHO also included the Internation- dience, their behaviors and perceptions, and the factors
al Multiple Micronutrient Antenatal Preparation (UN- which influence those behaviors. Formative research is
IMMAP) MMS formulation in the 2021 update of their particularly important for enabling researchers and pub-
Model List of Essential Medicines (known as EML), rec- lic health practitioners to identify potential obstacles
ommending its inclusion based on the strong evidence to future programming, such as participation barriers,
that MMS reduces LBW, SGA and preterm births, and and develop solutions to minimize or eliminate these
potential reduction of stillbirths and neonatal deaths, obstacles. Programming where MMS will be delivered
compared to IFA alone. would benefit from formative research, given the global
surveillance and monitoring data that have forecasted
This guidance provides an overview of the steps and both upstream and downstream challenges to deliver-
methods used to conduct formative research for im- ing and scaling-up MMS at the country level. Some of
proved MMS acceptability and utilization among preg- those factors include weak supply chains, low access
nant women. The guidance manual contents were to ANC services, and low-quality behavior change inter-
developed, in part, based on formative research con- ventions to support and motivate pregnant women. De-
ducted in Bangladesh, Burkina Faso, Madagascar, and spite abundant evidence of the efficacy of MMS, there
Tanzania. Lessons learned from conducting those for- is still the need to address evidence gaps and develop
mative studies were synthesized using a combination key insights on how to deliver MMS effectively across
of stakeholder feedback and evidence-based research different contexts. Doing so may help ensure that MMS
methods. This guidance provides specific information does not face the same fate as IFA of low program cov-
to help support the development and design of a for- erage globally (Berti el al., 2018). Well-designed for-
mative research process for introducing MMS or other mative research may yield socio-cultural and context
nutrition interventions, may be used by implementing specific findings as a first stage of program planning to
agencies and field practitioners when introducing MMS improve understanding of those social, behavioral, and
in country programs. The guidance offered in this man- systems-level elements important for MMS acceptance
ual may be adapted to each context, population, and and utilization of MMS.
country program based on available resources, capaci-
ties, and needs.

5
 STEP 1 | UNDERSTANDING THE CONTEXT

Prior to implementing formative research, understanding what is already known about a specific
context is important. Fieldwork can be time consuming and resource intensive; thus, documenting
the existing information available in a given country/area using a literature review of ethnograph-
ic analyses, peer-reviewed and grey literature is important. For example, a literature review can
help to identify the gaps in understanding what information needed to tailor programming is still
missing and should be investigated, avoiding losing time in collecting the same data twice. As
much as possible, search for documents that focus on the specific area where the project will be
carried out.

Multiple sources of country-level information are available for gathering this information such
as: sociocultural assessments, anthropological studies, Semi-Quantitative Evaluation of Access
and Coverage (SQUEAC) and Standardized Monitoring and Assessment of Relief and Transitions
(SMART) surveys, Knowledge, Attitudes and Practices (KAP) surveys, Demographic and Health
Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and health facility surveys. All of these
materials can provide rich information on context-specific causes of undernutrition, organization
of stakeholders, health services coverage, and determinants of key behaviors of interest.

To summarize literature review findings, compile the information in one document to first classify
the existing information into different sections/themes as well as to identify data gaps that need
to be filled using formative research methods. Doing so will help to clarify what information is
already known, or not known, about the factors influencing maternal care-seeking behaviors and
prenatal supplement usage. Example search terms are provided in Box 1.

Box 1: Examples of literature review search terms

Examples of relevant search terms that may be used to begin a literature review using Google Scholar:

• Multiple micronutrient supplementation (MMS) among pregnant women in [insert country name]
• Factors influencing iron folic acid (IFA) uptake and compliance in [insert country name]
• Barriers and facilitating factors of prenatal supplement usage in [insert country name]
• Determinants of antenatal care-seeking behaviors in [insert country name]

6
STEP 2 | DEFINING FORMATIVE RESEARCH OBJECTIVES, METHODS, & TOOLS

Formulating research questions

1. Start with clear research objectives to focus the study on the most critical information needed to
inform decisions and program design. Formative research can have more than one objective, but
each must be a clear statement about what the learning objectives are. Good research objectives
include a general objective and specific objectives; use action verbs such as “to determine,” “to
compare,” “to verify,” “to describe,” and “to assess.” Avoiding vague terms such as “to study” will
help your objectives be more precise. For example:

• Describe how and where women access prenatal supplements.

• Assess the perspectives toward maternal and child nutrition and health.
• Determine the process women follow to decide whether or not to use a prenatal supplement
(facilitators).
• Identify reasons why women do not take prenatal supplements (barriers).

2. Next, formulate research questions:

Using the information gathered, develop research questions that facilitate identification of knowl-
edge gaps and match the research objectives.
Narrow the list of questions to the ones that are most relevant and important for the research
(considering budget, time, and personnel constraints).

Examples of research questions related to maternal nutrition and MMS are included in Table 1
below.

TABLE 1: Example formative research questions related to maternal nutrition and MMS

Area Research Question

Access/availability What prenatal supplements are currently available to pregnant women? How
does availability impact pregnant women’s ability to improve their micronutrient
status?

Product attributes Which prenatal supplement product features /benefits do pregnant women
most desire?

Social Support To what extent are women encouraged to take prenatal supplements?
By whom?

Knowledge What are the prevailing knowledge, attitudes, and practices towards maternal
nutrition and prenatal supplements?

Affordability Who purchases prenatal supplements in the household and at what price?
What can women afford to pay for prenatal supplements?

7
 Finally, identify the appropriate combination of data collection methods that will most effectively
generate data to answer the established research questions:

• Formative research methods involve a variety of qualitative and quantitative methods to help
inform the eventual design of a project, and the approaches and methods used need careful
consideration.
• For example, the use of an ethnographic analysis (qualitative method) might be useful for
observing and/or interacting with study participants in their real-life environment.
• Free listing and pile sorting are other methods that help generate data to understand how
community members conceptualize foods and illnesses common to pregnancy. These meth-
ods are implemented with the help of an interview guide.
• Below is an overview of a few common methods, along with sample results from the four
countries (Bangladesh, Burkina Faso, Madagascar, Tanzania) in which this kind of formative
research was conducted.

8
Ethnographic analysis: Semi-structured Sampling interview participants
interviews • In interviews to inform MMS programming, exam-
ples of key informants to consider include pregnant
Understanding the lived experiences & perceptions of
women, health workers, and important influencers
pregnant women in the community
(e.g., fathers, grandmothers, community leaders,
etc.).
Overview • Purposively sample interview participants based on
Semi-structured interviews are best conducted using pre-defined criteria that are important to consider
open-ended questions covering a specific list of topics. in a given context. For instance, sampling women
They are useful to gain a general understanding of the who have had previous pregnancies and experience
reported practices, individual perspectives, and per- with IFA supplementation and/or women who will
sonal experiences of community members/pregnant be first time mothers.
women. • Community leaders and health workers may be
helpful for recruiting participants, but interviews
Typical objectives of interviews during MMS are one-on-one and should only include the inter-
formative research viewer and the participant.
1. To understand the typical experiences of
Additional resources for qualitative interviewing
women during pregnancy and lactation, in- This Handbook of Methods in Cultural Anthropology by Bernard
cluding challenges they face, cultural consid- and Gravlee (2014) is a great resource for people wishing to
erations, and practices they engage in for op- learn more about qualitative and ethnographic methods.
timal health and nutrition of mom and baby.
Data Analysis
2. To describe the specific barriers and facilitat-
ing factors important for optimal maternal nutri- Data analysis of interview transcripts is important for
tion and birth outcomes in this cultural context. answering the guiding research questions and inform-
ing MMS programming. Like the secondary data collec-
3. To generate social marketing-related recommenda- tion/literature review phase, it is useful to summarize
tions (product, price, promotion, placement) to in- the information collected in a document by theme, as
form culturally appropriate MMS programming for well as compare it to the literature review.
optimal acceptability and compliance.
Transcribe the recording verbatim from digital file to
Develop interview guides text file:
Semi-structured interviews are typically conducted by • Translation and transcription can be completed by
a trained data collector who uses a guide that allows for the data collection team but can also be completed
open-ended questions as well as leaves room for spe- by another person on the research team with lan-
cific probing on key areas of interest (see Annex 1 for guage and computer proficiencies.
an example interview guide). Furthermore, if interviews • While translating/transcribing, local terms for ill-
are conducted in a language other than English/the nesses, foods, and other important words/ phrases
language of the formative research team, it is important should be kept in local languages where translation
to ensure that translations reflect the open-ended na- may not be possible.
ture of good interview questions, with phrases such as
“could you tell me about…” and “describe for me…”, and
Develop an analytic template for summarizing key
include specific probes to accompany each open-ended
themes relevant to research aims:
question to elicit richer information on any given topic.
Another good approach is to create a unique interview • An analytic template is a table organized by re-
guide for each participant type – pregnant women, search question for compiling themes found during
health workers, etc. review of the transcripts.

9
Review the transcripts and identify key themes:
• Using the analytic template, organize key themes
found across transcripts for a summary of findings.
• A key theme can be thought of as a repeating idea
found in text across interviews or a repeating idea
mentioned by multiple individuals.

How many semi-structured interviews &

focus group discussions (FGDs) should be
conducted?

There is not a universal formula for determin-

ing interview or focus group discussion sample
sizes. Typically, data should be collected until
‘saturation’ is reached. Saturation refers to
the point in the research process when no new
relevant information about key topics emerges
from additional data collection. Sample sizes
should also consider the lowest unit of anal-
ysis. In other words, if interviews are being
conducted among pregnant women, commu-
nity leaders, and health workers to understand
their unique perspectives, then an adequate
number of interviews for each group/stratum
is necessary. For each participant type, you
might consider conducting no fewer than 8 – 12
interviews and 3 – 5 focus group discussions.
Additional data collection may be necessary if
your research questions are not fully answered
after reaching sample size targets.

10
Sample findings
Sample findings from interviews with health work-
ers and pregnant women in Tanzania are given in the
section below. These findings primarily focus on the
attitudes and perceptions of both participant types to-
wards MMS. Additionally, an example of application of
interview findings to develop a consumer archetype is
provided.

TABLE 2: Findings on lived experiences of pregnant women based on semi-structured interviews in Tanzania

Theme Key Quotes

Suggestions to Improve “In my opinion .. if it is health that we prioritize, it [MMS] must be distributed for free in hos-
MMS Uptake - Financial pitals, like the iron pill maybe it has to be all the time available and that people are not asked
to buy it”.
-Itasy, interview, pregnant woman

“There is also the price, if it is to help it [MMS] must be free. Because pregnant women cannot
work. There are those who have a lot of financial difficulty, victim of unwanted pregnancy, they
have no one to rely on when they cannot work. It would be nice if we gave it to them for free.”

Perceptions of MMS/ IFA “A pregnant woman has just given birth with a huge hemorrhage, that’s why all pregnant
women must take the iron battery to fight against this hemorrhage, to give energy to the moth-
er during her pregnancy, and not to lose a lot of blood during the delivery.”

“But if we say you will be strong and your baby will develop well if you take it [supplement],
they are motivated to take it even if it is exhausted, they will look everywhere.”

Suggestions to improve “What motivates them is what the midwife said they have to take it [supplement], she said it
MMS uptake – prevents bleeding, that’s why they took it.”
Key influencers
“It is these community workers who need to be motivated for this. Because they are at the level
of the target community, they see and know the people there, they see their habits on the daily
level and it would be easier for them to convince them about this product and people accept it
easily.”

“Because when we have our prenatal consultations, the doctor first gives us this medicine
[supplements], and then he saves our life.”

11
Using interview findings to create an
archetype
Formative research findings can be used for develop-
ing tailored communication approaches. Interview data
may be used to determine key attributes of the primary
audience segment in each setting. In this study, the pri-
mary audience is pregnant women. An archetype can
present information related to demographics, typical
diets, care seeking practices, experiences with prenatal
supplements, expected barriers/facilitators to MMS up-
take, communication channels, and emic (local) words
and phrases that can be used to promote MMS more
effectively.

FIGURE 1: An archetype of the typical pregnant woman created from formative research findings in Bangladesh

Archetypical pregnant woman in Bhola and Kurigram

Age range: 18 30 years old | Livelihood: Housewife, mother | Family: Husband, 2 3 children, mother in law | Location: Bangladesh
(Bhola and Kurigram) | Language: Bengali/Bangla

Typical diets during pregnancy Current care seeking practices Previous experiences with
• Typical diets rely primarily on rice as the sta- • Community clinics are the most accessed type prenatal supplements
ple food in every meal of facilities utilized for pregnancy services be- • Likely has previous experiences taking iron
• Animal sources are consumed to a much lesser cause of their location and affordability folic acid or calcium tablets
extent, even during pregnancy • Private clinics access is much more limited in • Supplements are sometimes purchased but
• Supplementation during pregnancy is com- Bhola and Kurigram mostly gotten for free at clinics
mon in this setting; most women have previ- • Hospitals are only visited for medical compli- • Current placement of prenatal supplements
ous experiences with it cations is at pharmacies and community clinics, but-
• Generally good knowledge of nutritious diets- • BRAC community health workers provide stock outs are frequent
during pregnancy, but limited finances remain home visits and are trusted members of the • Primary purchasers of prenatal supplements
a challenge to consuming them health system are husbands
• Some food prescriptions and food proscrip-
tions exist in this setting and may influence
dietary intake

Likely barriers to MMS Trusted communication channels Examples of salient Bangla phras-
acceptability & compliance to reach pregnant women es to use in MMS promotions
• Limited finances to access services where • Interpersonal channels: Community clinic • “Ma k pusti khaoai , ma o sishu k sustho rakhi
MMS may be provided is a likely barrier health staff (CHCP, FWA, HA), BRAC communi- “(feed mother nutrients, keep mother child
• Pregnant women’s health and nutrition de- ty workers, Doctors well)
cisions are influenced by family members, • Social mobilization: Community meetings • “Ma khele vitamin, Baccha thakbe sutho prot-
including in laws who may not support supple- • Media: Billboards, Radio, Print (brochures, job idin ” (If the mother takes vitamins, the child
mentation approaches aides), Television advertisements will stay healthy every day)
• Frequent stock outs of prenatal supplement at • “Ma jodi khai vitamin, baccha sustho thakbe
community clinics protidin ” (If the mother takes vitamins, her
• Persistent perceptions that prenatal supple- body will remain healthy every day)
ments yield large babies and result in Cesar-
ean sections
• Low risk perception toward illnesses during-
pregnancy may hamper MMS compliance

12
Ethnographic analysis: Free listing
Box 2: Resources for Free listing
Understanding the most important items within a
cultural domain This book Systematic Data Collection by Weller and Romney
(1988) by Sage Publications is available online and provides
Overview
guidance for free listing and pile sorting as part of cultural
Free listing is a simple exercise where participants are domain analysis.
asked to list items related to a specific topic; and aid
in the understanding of a cultural domain, such as “ill-
nesses” which includes a list of individual terms that
vary from one cultural context to the next. 2. To elucidate food prescriptions and food proscrip-
tions (i.e. taboos) that may exist during pregnancy
Prior to conducting free listing, develop the free list in the cultural setting where MMS will be introduced
guide (See an example in Annex 4) with the data col- 3. To understand the perceived importance of mater-
lection team, as well as recruit free listing participants nal nutrition (diet or supplementation) for pregnan-
with the help of community leaders, including health cy-related health and birth outcomes
workers, village headmen, and others that belong to the
same cultural group or conduct multiple free list exer- Data Analysis
cises with different groups.
At the end of each free listing exercise, the data col-
Example objectives lection forms should look similar to the table below
(Table 3).
1. To identify local illness and food terms to use in
tailored messaging to promote MMS during pro-
gramming

TABLE 3: Example of an abbreviated free list data collection form MMS formative research in Madagascar

Free List Questions #1 Comments to guide field notes

List all of the different illnesses, After listing, probe on the top 5 illnesses to get local explanations.
signs, or symptoms that you suffer Probe on any nutrition-related illnesses (e.g., anemia). Probe on any
from as a pregnant woman in this illnesses that seem confusing, new, or contradictory to you.
community.

1. Nausea “Usually I feel nauseous the first few months while pregnant. Also, when
taking iron-folic acid tablets I have felt sick previously.”

2. Vomiting “This just happens when you are pregnant after eating certain foods such
as tilapia (fish) or papaya.”

3. Dizziness “This happens when blood pressure is too high. We take herbal remedies
from the traditional healer for dizziness.”

4. Bleeding “I don’t know why this happens. If it is serious, then we go to the clinic.”

5. Baby too small “The midwife tells us that our diet affects the size of the baby but my
grandmother does not agree.”

6. Anemia “Anemia is common here but not so serious. Some people get transfusions
when it is a serious case.”

13
Sample findings pregnant women are malaria, vomiting and headache.
The only nutritional disease on the table is anemia,
Results of free listing exercises conducted in Burkina
which has a low salience, indicating that few partici-
Faso are provided in the table below. Free list terms are
pants mentioned it relative to the other diseases on the
shown in the local language along with a description of
list. Because nutritional illnesses are less salient in this
the term, the English equivalent, and the salience (how
context and anemia may be attributed to iron deficien-
important the illness or food is to the community and is
cy, using MMS as a solution not fit within the cultural
calculated based on frequency of mention.
domain of illnesses for pregnant women. Identification
Salient illnesses during pregnancy of emic (local) terms can help tailor messaging.
Looking at the table, the top diseases that affect

TABLE 4: Salient illnesses list – example from Burkina Faso

Local Brief emic (local) description of the term, Approximate Salience

illness term from participant description perspective English
equivalent

1. weogo Caused by mosquitoes and dirt. Can be treated with pills or injec- malaria 0.813
tions or traditional medicines including (leaves of acacia and eu-
calyptus tree)

2. woukré Symptoms related to pregnancy. Treatment at the health center vomiting 0.269

3. zou zabré Caused by exposition to the sun or symptom of malaria. Treatment headache 0.262
at the health center

4. nao fidme Illness related to pregnancy because you get it only during preg- edema 0.178
nancy. It can be also due to excessive consumption of salt during
pregnancy or long sitting position. Treatment at the health center

5. pou zabré Symptoms related to pregnancy. Treatment at the health center stomachache 0.165

6. yamsé Symptoms related to pregnancy because you get it only during preg- fatigue 0.160
nancy. Treatment at the health center

7. po zabré Caused by heavy workload or the bad conditions of the beds after Back pain 0.149
delivery. Treatment at the health center or at home with ointment
“Vitago”

14
Ethnographic analysis: Pile sorting 2. To assess maternal risk perception toward pregnan-
cy-related illnesses and birth outcomes
Understanding the ways that people typically classify 3. To understand how MMS fits into local understand-
items within a given cultural context. ings/descriptions of nutrition-related illness
Overview Data Analysis
Pile sorting builds off free list data to understand the The results of the pile sorts should be analyzed using
ways that people classify items in each cultural con- specific forms (provided in the appendix). Additional
text, which is important for informing context-specific resources for data analysis are displayed in Box 3 be-
social marketing promotions. For example, if free listing low.
‘nutritious foods to eat during pregnancy’ resulted in
15 food items, then pile sorting would present partici-
Box 3: Additional Pile Sort Analysis Resources
pants with 15 cards that each have a unique food item
written. This book Systematic Data Collection by Weller and Romney
(1988) by Sage Publications is available online and provides
Example objectives guidance for free listing and pile sorting as part of cultural
1. To define local food and illness classification domain analysis.
systems within a cultural context

TABLE 5: Pregnancy-related illnesses classifications from pile sorting in Burkina Faso

Local (Moore*) Illness Terms English Illness Equivalents Exemplar Description of cluster
Most serious illnesses

1. ziimzoesse 1. Bleeding
2. zimkalum 2. Anemia “These are serious illnesses. If they are not
3. tension 3. Hypertension treated, they can cause death.”
4. faible poids 4. Low birth weight -Pregnant woman, age 20
5. pouzabre 5. Stomachache
6. pezabre 6. Pelvic pain
7. toorezongogo 7. Vaginal itching

Moderately serious illnesses

1. po zabre 1. Back pain

2. nao fidme 2. Edema “These illnesses can rarely cause death and
3. zou zabre 3. Headache they are easy to treat.”
4. yaamse 4. Fatigue -Pregnant woman, age 35
5. nin yilnga 5. Diziness

Least serious illnesses

1. konsgo 1. Cough “These are also frequent among pregnant

2. yin wingre 2. Fever women and can be endured easily. They can
3. woukre 3. Vomiting disappear without any treatments”.
-Pregnant woman, age 35

*Moore is a local language spoken in Burkina Faso

15
Examples of quotations from participants are present-
ed below to explain participants’ reasoning behind the
pile sort categorizations.

“These are the most serious illness weogo (malaria),

woukre (vomiting), zou zabre (headache), po zabre (back
pain), ziim kalum (anemia), yin winger (fever), tension (hy-
pertension), faible poids de naissance (low birth weight)
because they can lead to death and miscarriages.”
(Pregnant woman, Yako, Burkina Faso)

“These are moderately serious illnesses (yamse (fatigue),

pe zabre(pelvic pain), tore zogongo (vaginal itching) and
konsgo (cough)) because they are easy to treat and do not
last longer.”
(Pregnant woman, Yako, Burkina Faso)

The quotes add additional context to the pile sorts. The

most severe illnesses are considered to cause death or
miscarriage, while the more treatable diseases are seen
as moderately severe. Additionally, diseases that allow
a woman to continue working are seen as least seri-
ous. Knowing that nutritional diseases are considered
most serious in this context is a facilitating factor for
improved acceptability and uptake of MMS as a solu-
tion. In many settings globally, risk perception toward
nutrition-related illnesses is lower than it is for other
common illnesses, thus presenting a behavioral barrier
even before programming begins.

16
Focus group discussions Sampling/identifying prospective participants
and a venue
Collecting community inputs for tailoring program de-
sign and implementation • No fewer than 2 focus groups should be conducted
per site, and 3 – 5 focus groups per site is recom-
Overview mended.
Focused discussions with a small group (usually 6 to • Recruit participants who have similar characteris-
12 people) of participants are key to better understand tics to one another – for instance, of similar age,
the attitudes, perceptions, and beliefs pertinent to the social status, cultural group etc.
issues being examined. These discussions will provide • Community leaders and health workers may be
multiple perspectives and build consensus around top- helpful to recruit participants
ics, and pick up on social norms, group dynamics, and • Work with community leaders to identify appropri-
concrete experiences linked to a particular behavior. ate venues to facilitate focus group discussions.
Participants of a focus group should have a similar pro- • Appropriate venues may include community-lev-
file and level of power for everyone to feel comfortable el structures where everyone feels comfortable to
expressing their views. openly speak.
In addition to open-ended questions, key tools for elic-
iting informative perspectives in focus groups include
Data analysis
participatory activities. A moderator introduces the
topic and uses a prepared interview guide with mostly Refer to the Semi-Structured Interview Data Analysis
open-ended questions to lead the discussion and elic- section for textual analysis guidance.
it discussion. Remember that focus group questions Sample findings
should be aimed toward the entire group rather than
Sample findings from Tanzania are provided below and
to specific individuals (See Annex 2 for an example of a
summarizes a few themes regarding the lived experi-
FGD guide, and tailor questions as needed).
ences of pregnant women. Column 1 summarizes per-
tinent themes identified through analysis of the focus
Example objectives group data and column 2 outlines key quotes that fur-
1. To understand social norms around health- and ther explain each theme. Column 3 summarizes find-
nutrition-seeking behavior during pregnancy and ings from focus groups in a narrative format. Import-
lactation ant themes were developed first using the three aims
2. To solicit feedback on social marketing materials described above. Transcripts were analyzed for quotes
for promoting MMS with a focus on appropriate that fit under each theme established from the aims.
promotions, placement/delivery mechanisms, and If there was evidence of another important theme not
product characteristics specifically addressed in the aims in the transcripts, this
3. To build consensus around more preferred strate- theme was added. After matching quotes to themes, a
gies for appropriately introducing MMS for optimal narrative was written to summarize the transcript data.
acceptability and utilization Key quotes that supported the narrative and clearly il-
lustrated the point of view of the participants are sum-
marized in Table 6.
Developing an focus group discussion guide
• Develop a focus group guide which is a discussion
or conversation guide that is used to conduct the
group.
• Compose questions that contain mostly open-end-
ed questions.
• Remember that focus group questions should be
aimed toward the entire group rather than to spe-
cific individuals.
• A sample guide provided in the Annex 2
17
TABLE 6: Findings on lived experiences of pregnant women based on focus group discussions in Tanzania

Theme Key Quotes

Challenges and experi- “When I was pregnant, I had many challenges including vaginal bleeding for the entire period
ences during pregnancy of pregnancy. I was also feeling dizzy and nausea to the extent that I could not eat properly”

“Most of the time I was feeling dizzy and had anemia”

Perceptions of IFA “IFAS increases blood in our body and should be taken daily”

“The tablets increase blood besides vegetables that also contributes to an increase in blood.
These tables also strengthen child’s body parts in-utero and after birth”

Challenges with IFA “I don’t like them at all. The challenges start when putting these tablets in the mouth, they
smell bad and makes me feel nausea and sometimes I vomit”

“I experienced nausea however, the challenges on the use of the IFAS differs from one person
and another. Other times I experienced body weakness, tiredness and sweating after using the
IFAS. Also, the odor is not impressive”

The findings above summarize experiences with preg-

nancy, perceptions of iron folic acid supplements and “We do get some information from mobile phone networks.
the challenges associated with their use. These find- When you have a mobile number and a handle, you may
ings can be used to develop an understanding of what register to get information about health and other things
it means to be pregnant in this community and how this you want to learn. You just need to write what you want”
experience affects uptake and perception of MMS prod-
ucts.
Social marketing inputs
Focus group findings can also be directly applied to From the selected quotes, health centers and mobile
the marketing of MMS. Consider developing materi- phone networks were identified as mechanism for pro-
als such as packaging design based on the workshop motion of MMS. Additionally, placing information at
findings and then asking for participant thoughts on health centers and educating healthcare workers on
these materials. Additionally, focus group findings on MMS could be another effective promotion strategy.
communication channels and target audiences can help
guide development of a marketing strategy by directly
applying these suggestions. The following are quotes
that summarizes some suggestions for MMS marketing
and promotion in Tanzania:

“We normally get all necessary information from the health

facilities” as said: P9: From health facilities and sometimes
other sources. For example, here in Kibole we have women
groups created specifically to discuss maternal issues in-
cluding supplements”

18
Participatory Workshops Select a venue
• Ideally, the location should be neutral such as a
Collecting community inputs for tailoring program de-
community center or common meeting space, rath-
sign and implementation
er than a headquarters or office of an implement-
Overview ing agency.
• Workshops can be held in open outdoor spaces;
Participatory workshops with diverse groups of com-
however, ensure that the participants feel comfort-
munity members allow them to brainstorm ideas and
able and have some level of privacy from the rest of
identify common barriers to maternal care seeking and
the community.
prenatal supplement usage. They will also allow for
brainstorming and ranking of preferred strategies (such
as promotional channels, logo/ slogan/ brand name Data analysis
preference etc.) to help overcome those identified A participatory community workshop will generate two
barriers. A guide should also be developed that con- types of data:
tains specific questions that can generate one word or
phrase responses. Questions on the guide should also 1. Numerical data in the form of vote tallies for each
reflect the three aims outlined above. An example guide question posed.
is provided in the Annex 3. 2. Textual data in the form of field notes written by the
recorder. Field notes will help to contextualize the
Example objectives voting data by explaining ‘why’ the top votes were
cast for each workshop question. Field notes can
1. To identify anticipated barriers to and preferred
also help explain disparate findings from different
solutions to help ensure optimal MMS acceptability
workshops.
and utilization in this setting
2. To gain consumer insights on MMS product char-
There is not one single approach to interpreting and re-
acteristics including colors, logo, slogan, and brand
porting workshop findings. Creating a summary report
name to be used locally
for workshop findings is an effective way to summarize
3. To build community consensus around preferred
key results for further application.
promotional strategies for introducing MMS includ-
ing inputs for culturally appropriate programming Sample findings
Sample community workshop findings from the pilot
Sampling/recruiting participants study in Tanzania are provided below to give examples
• Follow appropriate channels, such as working with to guide data collection. Additional suggestions are
community leaders and health workers, to recruit provided on how to best apply findings to development
participants. of MMS marketing strategies. The summary tables are
• Participants should be representative of communi- displayed for each question with the local language and
ty demographics and include community members English translations. Both the numerical data (table
who are stakeholders in MMS programming. This with top voted suggestions) and the textual data (qual-
includes pregnant women, lactating women, grand- itative quotes explaining top choices) are provided for
mothers or in-laws, as well as husbands. each question.
• It may be necessary to conduct separate workshops
for different d target groups/demographics.
• Although community leaders can help to organize
the workshop, they should not join in the activity
due to their potential influence over community
member participation.

19
Consumer insights on MMS product While others suggested white because of its resem-
characteristics blance to other drugs in stores.

The results from the participatory workshops in Tan-

“I’m also proposing white color because, people are used to
zania are provided in the section below. First, partici-
white colour tablets and reflect cleanness. Also, most tab-
pants were asked to suggest names for the supplement
lets that are white color has no smell” (Mother, Tanzania)
that would both draw the attention of users (pregnant
women) and encourage other women to use the supple-
ment. Multiple names in total were suggested however Participants also acknowledged the importance of slo-
one became more popular than others, “virtubisho vya gans for long-term impact of an MMS program. Seven-
mama mjamzito” (Table 7). teen slogans were suggested, the top voted slogan was
“vitamini bora sana” (super vitamin) followed by “okoa
In addition to suggesting names, participants were
mama okoa mtoto” (save mom save child) (Table 8).
also asked to vote on a preferred color scheme of MMS
packaging. Most participants favored green, red, or Lastly, participants were asked to vote on a logo for the
white MMS design. Participants had varying reasons MMS tablets with the aim of making them easily iden-
for choosing each color. Some participants voted red tifiable. The majority of participants had suggested a
because that is the color that people are familiar with. picture of a pregnant woman swallowing the tablet.

“I suggest the color to remain red because people are used “I would like if a pregnant mother appears there, she
to it, changing the color might make them think it is not should be shown swallowing these tablets because they
MMS tablet anymore” (Father, Tanzania) are made for pregnant mothers.” (Mother, Tanzania)

Some suggested green because of its similarity to

vegetables and plant-based medicine.

“I’m suggesting green color because even the vegetables

we are eating are green. This will make us remember their
importance” (Mother, Tanzania)

TABLE 7: Suggested names for MMS based on community workshop data from Tanzania

Suggested Swahili name English translation

1. Kitulo A name of Tanzania national park located at southern highland

2. Mama mjamzito Pregnant mother

3. Tusaidie Mungu God help us

4. Damu Blood

5. Umoja Unity

6. Kiongeza damu Blood enhancer

7. Virutubisho vya mama mjamzito Supplements for pregnant mothers

8. Mama na mtoto Mother and infant

9. Mkombozi wa akina mama Mother's saviour

20
Taking into consideration all suggestions by caregiv- Using the information gathered from the participatory
ers in workshops, eleven printed samples of packaging workshops, the optimal packaging to increase accept-
were created. Participants were then asked to vote on ability of an MMS product was generated for the Tan-
which packaging they liked the most. Package num- zania context. Package number three was altered to
bers 1 and 3 were the most popular. Participants pro- include a bolded title, be written in Kwahili, and use
posed minimal changes to each packaging and overall, a more realistic image such as the one from package
package number 3 was the favorite package. number one to create the optimal MMS packaging for
Tanzania.

TABLE 8: Suggested slogans to promote MMS based on community workshop data in Tanzania

Suggested slogan in Swahili words English translation

1. Boresha afya ya mama na mtoto Improve maternal and child health

2. Boresha afya ya mama mjamzito Improve the health of a pregnant woman

3. Meza dawa ikusaidie Take medication for self-help

4. Jipe moyo Give yourself hope

5. Karibu mama mjamzito Welcome pregnant mother

6. Virutubisho bora kwa akina mama Best supplements for mothers

7. Dawa tosha kwa mama mjamzito Sufficient tablet for pregnant mother

8. Dawa salama kwa wazazi Safe tablet for mothers

9. Sisi tunaweza We can

PACKAGE 1

PACKAGE 3

21
Barriers to MMS uptake

Another key question in the workshop guide asks par-

ticipants to identify challenges for MMS uptake. The
challenges identified in Bangladesh are summarized in
Table 9 below.
Understanding possible barriers to MMS consumption
is important to improving acceptability and adherence.
At the community level, caregivers reported poor road
conditions and limited supplies as a top barrier to MMS
consumption. However, most barriers were identified
at the individual level including adverse side effects,
unpleasant odor/smell, personal beliefs, and high cost
limiting availability. Recognizing barriers can help in
identifying modifiable factors, which can be targeted to
increase MMS consumption during programming.

TABLE 9: Reported barriers to prenatal supplementation in Bhola and Kurigram, Bangladesh

Reported barriers of
supplementation during
Supporting quotations
pregnancy

High cost of supplements “Of course, vitamins are required but we can’t afford the vitamins.”
Bhola, interview, pregnant woman

Supplement odor/smell “Many people do not like the vitamins that are available in the clinic; the medicine has a mild
odor, which is why many people do not want to eat [them].”
Bhola, interview, pregnant woman
“Yes, it’s smelly (iron). Iron and calcium cannot be taken due to their smell.”
Bhola, focus group, PLW

Physiological side “Many [women] say that they cannot take iron because it causes constipation. Though their
effects of supplements body needs vitamins, they [pregnant women] cannot take such vitamins due to these prob-
lems.”
Bhola, interview, health worker

Perception that supplements “Vitamin supplements make the baby large, for which babies cannot be delivered normally
can cause delivery complica- and require a C- section.”
tions Bhola, focus group, PLW

Limited access to supplements "The road to the clinic is not good and gets flooded during high tide."
due to poor road conditions Bhola, focus group, PLW
and stock outs "Medicines are not available in the clinics most of the time."
Kurigram, focus group, PLW

22
Direct observations Sample findings
Sample findings from the pilot study market observa-
Collecting quantitative data to corroborate and further tions are displayed below along with some ideas for
contextualize qualitative findings interpretation of results. The market observations will
provide data on the price of supplements, the range of
Overview products on the market, purchasing patterns, locations
Direct observations are useful in to gather quantita- where MMS is sold and promotional strategies. These
tive data that can be used to corroborate or expand on findings can inform optimal pricing for an MMS prod-
qualitative findings. For example, direct observations uct, modes of distribution, and promotion strategies.
may help to inform MMS marketing materials by pro- Findings from the market observations are combined
viding information about those locally-available sup- with data from interviews and focus groups to illustrate
plements currently preferred and utilized by the ma- how data from different methods can be used to com-
jority of women in each setting by directly observing plement each other.
markets in target communities to assess the types of
prenatal supplements being sold and cost of supple- Range of products
ments in addition to the places where supplements are Understanding the types of products currently available
sold. The instrument that should be developed to as- to consumers can help with deciding packaging design,
sist with direct observations is a checklist that includes unit type (ex: blister pack, pill bottle) and unit number.
observation-based questions. For example, in the case An example overview of the products found during mar-
of MMS questions should be focused on price, product ket observation in Burkina Faso (Table 10).
placement, and promotional strategies (a sample tool is
provided in Annex 5). Purchasing patterns – Who is the decision
maker, the buyer?
Example objectives
1. To understand the range of options where pre-natal Understanding who buys MMS can help in determine
supplements are currently being sold/distributed to who should be targets of advertising. While pregnant
pregnant women in this setting women are the target users, they may not be the pri-
2. To describe the range of existing pre-natal supple- mary purchasers. For example, in Bangladesh, two
ments and their preferred characteristics available thirds of interviews with shop keepers and pharmacists
in the current market during market observations explained that husbands
3. To inform social marketing inputs related to optimal are the primary purchasers of prenatal supplements in-
MMS product, price, placement, and promotions tended for pregnant women. From this finding, it may
be helpful to target male family members with MMS
Data analysis advertising. Interview data corroborates this finding by
Simple descriptive statistics should be used to analyze providing additional context as to why husbands are a
the results from direct observations. Analysis will vary good target for advertising.
based on the questions in the data collection tool, how-
ever, a few examples of key data points are provided
It would be better to bring the husband to the [communi-
below:
ty-level] meetings. Since they buy vitamins from the market
• The percentage of markets that sell supple menta-
they need to know about them.” (Pregnant Woman, Bhola)
tion could be calculated.
• Average cost of supplements in the community
should also be calculated.
• Purchasing patterns could be represented by per- “If there is such a big billboard in front of the clinic or in
centage of shop owners who report that women front of a shop, then the husbands of pregnant mothers
primarily purchase supplements may read the billboard and go home and share it [MMS
information] with their wives.” (Pregnant woman, Bhola)

23
Pregnant women in both study sites explained hus-
bands often work long hours and are primarily involved
in making household decisions related to finances.
Pregnant mothers emphasized the importance of in-
cluding husbands in MMS promotion.

TABLE 10: Prenatal supplements available in the current market in Burkina Faso

Prenatal Point of Galenical Presentation in Supplement

Supplements sale/ Form which Supplements Contents
Distribution being sold/
Distributed

Denk Prenatal PP Tablet Box of 30 Vitamins B1, B2, B6 and

B12, niacin, folic acid,
vitamin C and E

Gestarelle PP Tablet Box of 30 Vitamin B9, vitamin D,

Iodine, iron, Omega 3, 8
vitamins and 2 minerals

Alvityl Comprimé PP Tablet Box of 40 Vitamins, Minerals

Astymin Forte PP Tablet Box of 20 Multivitamins, Essential

amino acid

24
STEP 3 | USING FORMATIVE RESEARCH
TO INFORM THE DESIGN OF AN MMS PROGRAM/INTERVENTION

Step 3 is used to test intervention strategies developed using findings from Steps 1 and 2 in an it-
erative design. Ethnographic findings from Step 1 may be used to generate local terms and phrases
for tailored messaging promoting MMS, while participatory findings from Step 2 may be used to
inform choice of intervention strategies that may assist pregnant women in overcoming key barri-
ers to antenatal care and MMS usage. A few such strategies include:

Using formative research findings to design a social and behavior change communication
(SBCC) approach

Behavior change is an inherent part of most health and nutrition interventions, and in order to sus-
tainably contribute to nutrition outcomes, it is necessary to influence people's behaviors. It is gen-
erally complementary to providing access to goods or services as it helps maximize their use and
benefit. Findings from the literature review and primary data collection collected during formative
research can be organized organize and distilled into an evidence-based SBCC strategy. For exam-
ple, the research findings from Tanzania above noted sociocultural barriers to MMS uptake and
adherence such as adverse side effects, unpleasant odor/smell, and personal beliefs, that could be
modified using a strong SBCC approach to increase MMS consumption during programming.

Using formative research findings to design a gender-responsive program design

Gender responsive programming refers to program where gender norms, roles and inequalities
have been considered, and measures have been taken to actively address them by narrowing and/
or removing gender inequalities. Formative research can be used to inform gender-responsive
programming (in health interventions) by identifying barriers and enablers to accessing and using
health services and incorporating qualitative inquiry and engagement approaches into formative
research in a way that generates evidence to develop the program.

25
 STEP 4 | PLANNING FOR FORMATIVE RESEARCH

Developing a timeline and budget

How long does it take to carry out formative research? The time required depends on many
factors, including, but not limited to: availability of personnel, funding, logistics, sample size, size
of the intervention zone, training needs, the timeframe before implementation of a program, and
the scope and depth of the assessment. Literature reviews can take two to five days, depending on
the scope of the research. The primary data collection will take longer, as to allow time to talk to
members of the community, and plan focus group discussions and interviews. An example timeline
of activities is provided below in Figure 3. It is important to note that there should be at least a
week in between each step to complete preliminary data analysis and check data quality before
moving on to the next step. Timelines will vary across country programs with some steps moving
more quickly than others based on local factors.

Attaining ethical approvals

Typically, ethical approval should be attained, at minimum, through the national ethics committee
in the country where the work is being conducted. Sometimes, if an international university is
involved, then a second ethics approval will also be needed from that supporting institution. In
some cases, sub-national approvals (e.g., regional, district) are also required. Ethical approvals
often require a detailed research protocol, finalized data collection instruments and consent forms
in both a national language and all local languages, letters of support, and study personnel details,
among other items.

FIGURE 3: Example of a 12-month formative research timeline of activities from planning

through final report submission

26
Preparing all necessary materials for ethical approval submissions and waiting for institutional
boards to grant approvals at all required levels may take between 2 – 6 months in most cases.
Once institutional research boards grant the necessary approvals to proceed with human subject
research, then informed consent must be obtained from each study participant prior to data col-
lection. Planning ethics approvals into a program timeline will be an important consideration.

Box 4: Research Ethics E-learning Training Resources

• The Collaborative Institutional Training Initiative (CITI) provides no-cost training modules for study per-
sonnel to complete for research ethics certificates that are needed for most institutional research board
submissions. The suite of training modules can be completed in multiple languages and is widely accepted.

• FHI360 offers a Research Ethics Training Curriculum that can be utilized for training study personnel,
including data collection team members, prior to fieldwork activities.

• The Global Health Training Center has developed a Research Ethics Online Training which has been adapt-
ed from an e-learning course that was produced by the World Health Organization.

27
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29
 ANNEX 1: SEMI-STRUCTURED INTERVIEW GUIDE
Semi-Structured Interview Guide (pregnant women)
Demographic Information
Data Collector Name: ____________________ Date: ___________
Location: _________________

Introduction
Thank you for taking the time to speak with me. To start, can you please tell me about your family? Could
you please tell me about a typical day for you? Now can you tell me about the resources available for
pregnant women in this community?

Antenatal Care:
• Now I would like to know more about health during pregnancy in this community.
• Can you please describe what a healthy pregnancy should look like?
• Can you please describe any changes to your diet after you became pregnant?
• Probe on any advice regarding diet during pregnancy received
• Probe on who gave her the advice
• Probe on foods that are good for pregnant women
• Probe on foods that pregnant women should avoid
• Probe on how easy or difficult it is to maintain a healthy diet during pregnancy
• Can you please describe the illnesses that pregnant women in this community suffer from?
• Probe on seriousness of illnesses
• Probe on diseases she is most concerned about
• Probe on consequences of untreated illness
• Probe on the cause of each illness
• Probe on prevention of each illness
• Probe on treatment
• Can you describe any health care you have received from the time you knew you were pregnant to
now?
• Probe on healthcare seeking practices
• Probe on how receiving this care is prioritized
• Probe on knowledge of when to seek care
• What barriers do women in this community face in staying healthy during pregnancy?
• Probe on community support
• Probe on family support
• Probe on access to care

Micronutrient Supplement
This is great information. Now I would like to hear your thoughts on micronutrient supplements.
• Can you describe how a micronutrient supplement could help you stay healthy during your preg-
nancy?
• Probe on illness prevention

30
• Can you describe any similar products that you or other pregnant women in your community use?
• Probe on source of supplements
• Probe on availability
• Probe on affordability
• Probe on sharing
• Probe on what makes them desirable
• Probe on products that are not desirable
• Probe on perception of product
• Probe on other medications used during pregnancy
• Can you describe how these products were explained to you?
• Probe on who told her about these products
• Probe on how effective this explanation was
• Probe on how it could be improved
• Can you please tell me how to best market a micronutrient supplement to pregnant women in this
community?

Thank you for your time. Is there anything else you would like to discuss that was not brought up?

Semi-Structured Interview Guide (health workers)

Demographic Information
Data Collector Name: ____________________ Date: ___________
Location: _________________

Introduction
Thank you for taking the time to speak with me. Could you please tell me about your role in the commu-
nity? Tell me about a typical day as a health worker?
Can you please describe what health care resources there are for pregnant women in this community?

Antenatal Care:
• Now I would like to know more about health during pregnancy in this community.
• Can you please describe what a healthy pregnancy should look like?
• Can you please describe the illnesses that pregnant women in this community suffer from?
• Probe on seriousness of illnesses
• Probe on consequences of untreated illness
• Probe on the cause of each illness
• Probe on prevention of each illness
• Probe on treatment
• Can you tell me about illnesses that you are most concerned with?
• Probe on seriousness of illnesses

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 • Tell me about the care that a pregnant woman receives over the course of her pregnancy.
• Probe on any nutritional advice given to pregnant women
• Probe on any resources provided to women
• Probe on if advice is followed
• Probe on if resources align with advice
• Probe on reasons why women may or may not follow advice
• Probe on healthcare seeking practices

• What barriers do women in this community face in staying healthy during pregnancy?
• Probe on community/family support
• Probe on access to care

Micronutrient Supplement
This is great information. Now I would like to hear your suggestions about developing a program that
will introduce a micronutrient food supplement

• Can you describe how a micronutrient supplement would help a woman stay healthy during her
pregnancy?
• Probe on illness prevention

• Please describe how you distribute supplements to pregnant women

• Probe on availability of supplements
• Probe on supply of supplements
• Probe on any changes to supply of supplements

• Can you describe similar products that pregnant women in this community use?
• Probe on source of medications/ supplements
• Probe on affordability
• Probe on sharing
• Probe on what makes them desirable
• Probe on products that are not desirable
• Probe on acceptability of micronutrient supplement
• Probe on perception of product

• Please describe the most effective way to market a micronutrient supplement in this community?
• Probe on availability of supplements
• Probe on supply of supplements
• Probe on any changes to supply of supplements

Thank you for your time. Is there anything else you would like to discuss that was not brought up?

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ANNEX 2: FOCUS GROUPS DISCUSSION GUIDE
Demographic Information:
Data Collector Name: _________________________ Date: ______________
Location: ____________________ Number of participants: _____

Introduction:
Thank you for taking the time to speak with us today. We would like to hear your thoughts on micronu-
trient supplement s and supplementation during pregnancy.

• To start, can everyone tell us a little about their family?

Antenatal Care:

• Please describe any medical care you receive from the beginning of your pregnancy to the end of it.
• Probe on where healthcare is received
• Probe on access to care
• Probe on changes in access to care

•
What are some common challenges that women face during pregnancy? Can you tell us about your
experience with these?
• Probe on challenges related to nutrition
• Probe on social support

MMS Products:

• Now let’s discuss your experience with supplements during pregnancy. We have heard that many
pregnant women in this community use X (country specific). Can you tell me why that is?
• Probe on what makes these products desirable
• Probe on products disliked by the community and reasons why
• Probe on how these products are used
• Probe on how easy or difficult it is to use the supplements
• Probe on how important the use of these products are to pregnant women
• Can you describe any barriers in getting or using these supplements?
• Probe on availability
• Probe on affordability
• Probe on where supplements are sold
• Can you describe how these supplements might help you during pregnancy? Can you please explain
why that is?

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 MMS Promotion:

• Now we would like to hear your thoughts on how these products should be promoted in this com-
munity.
• Can you describe what a product should look like to make it attractive to pregnant women?
• Probe on colors
• Probe on logo
• Probe on names
• Probe on colors, names and logos that should not be used
• Can you tell us where this product should be promoted?
• Probe on where pregnant women often get health advice
• Probe on health advertisements in the community
• Can you tell us who this product should be marketed to?
• Probe on advertising to fathers
• Probe on differences in messaging depending on audience

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ANNEX 3: PARTICIPATORY WORKSHOP GUIDE
Demographic Information
Data Collector Name: ____________________ Date: ___________
Location: _________________ Number of participants: _____

Introduction
We would like to hear your suggestions on developing a brand for a micronutrient supplement specifi-
cally for pregnant women. Please express your ideas freely; there are no right or wrong answers. We will
be asking you a series of questions and will vote on your responses.

Section 1: Challenges and solutions

• What are the challenges women in this community face in taking prenatal supplements?
• Let’s vote on the top 5 challenges. You have 5 votes and can use all 5 on one idea or split
them up.
• What are some solutions to these challenges? What could make it easier for women to regularly take
a prenatal supplement?
• Let’s vote on the top 5 solutions.

Section 2: Branding
Discuss common brands in the community focusing on colors, names, logos and slogans. Use brands like
sports teams as examples.

• Now, we would like to discuss how a micronutrient supplement should look to make it attractive to
pregnant women in this community. We will be asking for your ideas for the color, name, logo and
slogan for this product. Let’s start with color. Please brainstorm a color scheme that you think would
suit a product like this.
• Let’s vote on the color schemes. You have 5 votes and can use all 5 on one idea or split them
up.

• Next, we would like you to think about a good name for a product like this. The name can be one,
two or three words.
• Let’s vote on the names. You have 5 votes and can use all 5 on one idea or split them up.

• Now, let’s think about a good slogan to represent this product. The slogan could be a short phrase
that is memorable.
• Let’s vote on the slogans. You have 5 votes and can use all 5 on one idea or split them up.

• Now, let’s discuss what a good logo would look like. The logo could be a simple picture that rep-
resents the name and the slogan of the product.
• Let’s vote on the logo ideas. You have 5 votes and can use all 5 on one idea or split them up.

Thank you for your participation. Does anyone have any additional questions or comments?

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 ANNEX 4: PILE SORTING GUIDE
Demographic Information
Data Collector Name: _______________________________________
Date: ____________ Location: _______________
Respondent characteristics: Age:______ Number of Children: _

Q1 | Maternal Illness: In order to help me understand more about illnesses pregnant women experi-
ence in this community, I’d like to ask you to tell me which illnesses go with each other. I’ve made a list
of some illnesses that are commonly experienced here. Please sort these illnesses into piles, in whatever
way you think is best, in as many piles as you wish. There is no right or wrong way. (Rules: respondents
may not put all illnesses into one pile or separate them into each into its own pile.)

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Q2 | Illness Severity: Now I want you to re-sort these cards. In order to help me understand more
about illness in this community, I’d like to ask you to put these illnesses into 3 piles based on how severe
they are: 1) most severe, 2) moderately severe, 3) less severe. There is no right or wrong way; it is just
your perception.

Q2 | Pregnant Women Foods: In order to help me understand more about food in this community, I’d
like to ask you to tell me which foods go with each other. I’ve made a list of some foods that are com-
monly eaten here among pregnant women. Here they are. Please sort these foods into piles, in whatever
way you think is best, in as many piles as you wish. There is no right or wrong way to do this.

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 Potential follow-up questions for explanations of each pile
• Tell me about pile X, Y, Z, etc. and how these cards are similar
• I notice that these cards are in different piles. Could you explain that for me?
• If you could name each of these piles, how would you do so?

Pile Sorting Analytic Framework

Topic: ____________________________________ Community: _______________________
Instructions: For ease of reference, record each food used for the pile stored in the appropriate space
below:

Instructions: Examine the pile sort data in form 3.1.1. Each time foods are in the same pile, put a tick
mark in the appropriate intersection box in the matrix below. Use only the un-shaded boxes.

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FORM 4: Tabulation Sheet For Pile Sorts

Instructions:
Most close: From form 8, find 8 to 10 items that were most often placed in the same pile. Write the
names of the two items and the percent of times they were put together in the same pile in descending
order of frequency. On the right-hand side, write the most common explanations for why these items
were seen as similar to each other.

Most Distant (top 5-6)

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 ANNEX 5: FREE LISTING GUIDE
Demographic Information
Data Collector Name: _______________________________________
Date: ____________ Location: _______________
Respondent characteristics: Age:______ Gender:________ Number of Children: _

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ANNEX 6: DIRECT (MARKET) OBSERVATION GUIDE
Walk through each market looking for prenatal supplements. Fill out sections 1 and 2 based on what you
observe. Pick one selling location and ask the owner of that shop or pharmacy the questions listed in
section 3.

Section 1: Supplements:
Fill out the following table for the prenatal (both MMS and IFA) supplements identified while walking
through each market. It is helpful to take photos of interesting displays or packaging.

Total number of selling locations for prenatal supplements: ________

Total number of supplements identified: _________

Section 2: Advertising
Use the table below to document advertising for any prenatal supplements. Advertising could be in the
form of posters, displays in stores, etc.

Total amount of advertisements observed: __________

Section 3: Survey with shop or pharmacy owner

Find a selling location that sells at least one of the supplements listed in Section 1. Fill out the demo-
graphic information and ask the questions listed below to the shop owner. You can either write the
responses on the tool or record the interview on a recording device.

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 Demographic Information
• Type of selling location: _________________________________
• Number of supplements sold: ____________________________
• Names of prenatal supplements sold: ______________________
• Price of supplements at selling location: ____________________

Supply Questions
• How many supplement types do you usually sell?
• How often do you receive shipments of these products?
• Describe any changes in prenatal supplement supply quantity over the year.
• What are some reasons why supply amounts change?

Demand Questions
• Who usually buys these products?
• Are there ever times where people are looking to buy prenatal vitamins, but you are out of stock?
How often did this happen in the past month?

Product based Questions

• Which supplements sell the most? The least?
• Why do you think people prefer the supplement that sells the most?

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