Acceptability and use of cereal-based foods in refugee camps: case studies from Nepal, Ethiopoa and Tanzania

By Catherine Mears with Helen Young

Outbreaks of scurvy, pellagra and beri beri among refugees in the 1980s caused a public outcry, as many of these more unusual deficiency diseases were thought to have been all but eradicated. Humanitarian agencies sought a wide range of solutions including micronutrient fortification of foods to overcome these deficiency diseases.

A recently completed research project focused on two strategies that are currently employed to enhance micro-nutrient intake of emergency affected populations; I) the inclusion of fortified blended food in the refugee food rations and ii) the fortification of cereals at local or household level - in particular the opportunities for the fortification of cereals with micronutrients at local or household level. Presently, inclusion of fortified blended foods in the general ration is a much more commonly adopted strategy than fortification of cereals.

This research represents an unusual and probably unique collaboration between an international Non Governmental Organization (Oxfam UK/I); the United Nations High Commissioner for Refugees, the Micronutrient Initiative and the World Food Programme.

Methodology

Field studies were undertaken in three sites (Bhutanese refugees In Nepal, Somali refugees in Ethiopia, and Burundi refugees in Tanzania). Qualitative methods were used, including key informant interviews, observation, semi-structured interviews, briefing and de-briefing sessions, and review of secondary sources.

Findings

All sites had a history of acute malnutrition and micronutrient deficiency and the planned ration was found to be deficient in micronutrients. A proportion of the food rations was sold by refugees in all sites, although blended food was sold on a very small scale,relative to the sale of other commodities . The items purchased by refugees were mostly food items, principally vegetables and more of the same or an alternative staple.
No preparation methods were observed, which seemed to be more than usually detrimental to the micronutrient content of the ration food, except multiple washing of rice (Nepal) and sieving of blended food (only by a small minority). Cooking methods of blended food varied between sites but were appropriate, even though it was only in Nepal that refugees had been explicitly informed about the fact that blended food were pre-cooked so that cooking time could be adapted accordingly.

A preferential bias in food allocation to men was implied as women described the pattern of allocation and consumption at meal times. However, blended food was used and valued in all sites as a complementary food for infants. All members of the household in all sites, were said to be eating blended food, but children tended to be given another serving later in the day if they asked. This is not the same as saying that it was mostly eaten by children.

Acceptability of blended foods was influenced by a wide range of factors. Familiarity was associated strongly with acceptability, but unfamiliarity did not always indicate low acceptability. Blended food appeared to be highly acceptable, even though the product 'per se' was not familiar, it was easily recognisable as a porridge and/or fashioned into an already familiar dish. The perceived and actual quality of the blended food and/or the cereal staple, was an issue in all sites. Acceptability was also affected by the identification of a particular ration food with a visible improvement in health conditions in Nepal and in all sites blended food was identified with a nutritious porridge they had known before. Resale value influenced the level of acceptance of the staple grain. The resale value of blended food was relatively low.
Acceptability was affected by whether refugees perceived the food item to be in the ration at the expense of the reduction or removal of another commodity. There was also a considerable degree of pragmatism expressed by refugees when reflecting on their situation. Familiar foods and cooking methods were largely maintained, but not to the exclusion of innovations which were understood to be beneficial, such as parboiling rice, or using improved stoves.

The feasibility of fortifying the staple cereal at regional (before distribution), camp (after distribution), and household (after distribution) level was considered. The study concluded,that regional level fortification would require adequate milling capacity relatively close to the refugee population, a medium to long term commitment by donors, and considerable technical and management expertise at the milling site. It would be most appropriate where milled cereal was highly acceptable and mostly eaten, not sold or exchanged. Camp level fortification would require adequate, affordable and accessible camp level milling capacity for the total population, and training and close monitoring of mill technicians, with particular reference to the even mixing of the fortification mix. It would be most appropriate where the staple grain was eaten in milled form and highly acceptable, or if not, was sold or exchanged to obtain an alternative whole grain eaten in milled form.

Fortification of cereal at the time of grinding or pounding at household level did not appear to be a feasible option due to limitations such as time, containers, space, and standard measures. Furthermore, when not sold or exchanged, the staple grain was not always milled to flour prior to consumption, or if so, was taken to the machine mill. However a household level fortification mix in the form of a salt could be added during cooking as salt and/or spices were used routinely in all sites. Use and acceptability of such an additive would need to be researched.
The study protocol had anticipated that the focus for review of blended food as a strategy would be on aspects of its use and acceptability. The study did not reveal major problems with either of these aspects but did highlight some technical and operational issues of quality control and timely supply of the locally produced products. As anticipated, the strategy of cereal fortification was shown to involve major issues of technical and operational feasibility in the two African sites. However the study revealed aspects of cereal use and acceptability which would also need to be considered for successful implementation of cereal fortification .

Report available from Oxfam GB:Publication date:March 1998-06-02 Price: £12.95
Extent: c160 pp ISBN: 0 85598 402 3