Appetite 59 (2012) 377–384

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Appetite

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Research report

Constructing maternal knowledge frameworks. How mothers conceptualizecomplementary feeding q

Eva C. Monterrosa a,b,⇑, Gretel H. Pelto a, Edward A. Frongillo b, Kathleen M. Rasmussen a

a Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, United Statesb Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina,800 Sumter St., Room 216, Columbia, SC 29208, United States

a r t i c l e i n f o a b s t r a c t

Article history:Received 9 February 2012Received in revised form 16 May 2012Accepted 31 May 2012Available online 11 June 2012

Keywords:Maternal knowledgeComplementary feedingEthnographyFormative researchEmic perspective

0195-6663/$ - see front matter � 2012 Elsevier Ltd. Ahttp://dx.doi.org/10.1016/j.appet.2012.05.032

q Acknowledgements: The authors would like toNational Institute of Public Health, Mexico for their iNeufeld PhD for her critical review of an earlier drafttwo reviewers for their insightful comments. We acfrom DNS Small Grants, Human Ecology Alumni Fund,International Studies, Cornell University.⇑ Corresponding author.

E-mail address: emonterr@mailbox.sc.edu (E.C. Mo

This ethnographic study examines maternal knowledge, and develops an emic framework to help explainand interpret maternal complementary feeding behaviors. In-depth interviews and home observationsamong 29 women with young children 6–18 mo were conducted in Morelos, Mexico. Transcripts weresystematically reviewed to identify major themes related to feeding young children, and data were codedusing a combination of preselected codes and codes that emerged from the identification of themes.Observations augmented the information that was obtained through verbal exchange. We identified eightconcepts: (1) probaditas (the idea of introducing small tastes of foods), (2) preparing separate foods forinfants, (3) readiness to eat solid foods, (4) appropriate consistency, (5) the value of variety, (6) child likesand dislikes, (7) money and food costs, and (8) healthiness of foods (positive and negative foods). Therewas strong evidence of cultural consensus (sharing of knowledge among the respondents), and theunderlying motivation was to provide foods to ensure good growth and health. This knowledge frame-work guided practices. Mothers fed their children liquid and semi-liquid foods, and fruits, but few veg-etables, meats, and legumes. Variation in the variety of children’s diets was associated with householdfactors, which emerged in the ethnographic interviews. We conclude that elucidating maternal knowl-edge frameworks is crucial for explaining maternal behavior, and argue that these frameworks are thefoundation for developing behavior-change interventions.

� 2012 Elsevier Ltd. All rights reserved.

Introduction

There is general agreement that change agents need to have abasic understanding of the cognitive systems, values, and behav-iors of the target audience (Schweizer, 1998), and many strategiesare available to assess target behaviors and their determinants be-fore designing an intervention. These include surveys, focusgroups, and interviews in what is usually referred to as formativeresearch (Margetts, 2004). The aim of formative research is to elu-cidate the constraints, facilitators (or enablers), and motivators,including beliefs, attitudes, actors, as well as the communicationchannels that influence maternal behavior change (Dicken, Grif-fiths, & Piwoz, 1997; PAHO, 2004). Formative research on comple-mentary feeding has yielded information on social and cognitivedomains. Social domains include maternal education, employment

ll rights reserved.

gratefully acknowledge then-kind support and Lynnetteof this paper, as well as the

knowledge financial supportand Mario Einaudi Center for

nterrosa).

outside the home (Alvarado, Tabares, Delisle, & Zunzunegui, 2005),and referents in feeding advice (Heinig et al., 2006). Cognitive do-mains include perceptions of infant readiness to receive foods(Alvarado et al., 2005) and caregiver knowledge of nutritious food(Dutta, Sywulka, Frongillo, & Lutter, 2006; Guerrero et al., 1999). Informative research, the social domain is often considered as a bar-rier to achieve a desired behavior, while the cognitive domain as anexplanation for behavior change (Yoder, 1997).

Formative research is usually undertaken from an etic or whatwe call ‘‘the researcher’s perspective’’ (Pelto & Pelto, 1978). Etic re-search has its limitations because it tends to view behaviors asproblems rather than understanding the process that gives rise tothem. Furthermore, the research begins with the preconceptionsand assumptions that are deeply imbedded in the investigators’knowledge systems, not those of the community. Thus, the eticperspective fails to yield accurate descriptions because it inevitablyreplicates the assumptions and perspectives of the researchers.

From a technical perspective, what is required are emic frame-works (Pelto & Pelto, 1978) or models of maternal knowledge ofcomplementary feeding (Pelto, Levitt, & Thairu, 2003) to under-stand how caregivers themselves conceptualize complementaryfeeding. These frameworks are achieved through ethnographicmethodologies that preserve the participant’s point of view

378 E.C. Monterrosa et al. / Appetite 59 (2012) 377–384

throughout data collection and analysis (Pelto & Pelto, 1978). Com-plementary feeding is not viewed as a problem (e.g., few nutrientdense foods) but as an expression of maternal knowledge (Wolcott,1999) and the social relationships and material conditions (Pelto &Pelto, 1978, 1997; Yoder, 1997) that define the process of comple-mentary feeding. Emic frameworks have been useful for changingmaternal behavior during diarrheal illness and convalescence(Bentley, 1988; Bentley, Stallings, Fukumoto, & Elder, 1991) as wellas for changing caregiving practices for acute respiratory infections(Pelto, 1996).

In this study conducted in Mexico, we aimed to make explicitthe knowledge structure of complementary feeding by construct-ing an emic framework of how women in the community we stud-ied feed their infants and young children. This framework providesa rationale for complementary feeding behaviors and serves as thefoundation for subsequent work on behavior change. The need toimprove complementary feeding practices in Mexico is evidencedby the following: (a) 25% of the infants in low-income householdsdo not regularly consume cereals, legumes and animal food prod-ucts by 9 mo, (González-Cossío, Rivera-Dommarco, Moreno-Ma-cias, Monterrubio, & Sepulveda, 2006); (b) 15% of children under2 y are stunted (González-Cossío, Rivera, González-Castell, Unar-Munguía, & Monterrubio, 2009); and (c) improving complemen-tary diets is a priority for the Mexican National Institute of PublicHealth (INSP, acronym in Spanish) (González-Cossío et al., 2006).

Methods

Theoretical perspective

Complementary feeding can be viewed as a cultural practice be-cause it is a manifestation of cultural knowledge. Spradley (1972)proposes that cultural knowledge encompasses all the necessaryinformation, such as beliefs, rules, ideas, and concepts, needed tointerpret experiences and generate behavior. Thus, in this defini-tion, culture is a mental construct that organizes human action.The result of this cognitive (if not always explicit) process is knowl-edge that is goal-oriented (Pelto & Pelto, 1997; Spradley & McCur-dy, 1975). In this study, maternal knowledge includes beliefs,nutrition/medical facts, rules, ideas, and concepts that are usedfor organizing mothers’ experiences with complementary feeding.Knowledge consists of clearly articulated elements (e.g., beliefs)and tacit elements that are less accessible for discussion (Pelto &Pelto, 1997) but accessible through observation (Yoder, 1997). Eth-nography is the appropriate methodology for the study of culturebecause it builds a systematic understanding of behavior fromthe perspective of the participant (Spradley, 1979), allowing oneto elucidate the knowledge that women use to interpret actionsand events around complementary feeding.

We used a biocultural model to guide our ethnographic ap-proach. This model centers child feeding around a food-producingsystem that focuses on the physical, social, and cultural domains(Jerome, Kandel, & Pelto, 1980).We examined the foods availableat the local market, food venues, and convenience stores and askedabout trips to larger urban centers to acquire food. We focusedmostly on the household as a pivotal determinant of complemen-tary feeding practices (UNICEF, 1998). We asked about and ob-served for foods available and consumed in the home (e.g., typeand timing of meals, snacks), the mother’s eating patterns (via a24-h dietary recall), caregivers involved in child feeding, particu-larly matriarchs or older female siblings, as well as maternalemployment and maternal activities in and outside the home.We inquired about having enough money to purchase foods anduse of government assistance programs. We asked about breast-feeding and the timing of introduction of solid foods, foods usually

consumed by the young child, 24-h diet recall of the child, child’sfood preferences, and feeding advice received from family mem-bers and health-care workers.

Study area

Our field site was located 40 km south of Cuernavaca in thestate of Morelos and was easily accessed by a highway. We choosethis community primarily because INSP has been working there formore than 20 y, maintaining a public health center, along with apublic health nurse and gynecologist to serve the community.There are 21,000 inhabitants, of whom 5606 are women of child-bearing age (15–49 y) (Salud, 2007). The main occupation of themale head of household is agricultural or construction laborer(Neufeld, Hernandez-Cordero, Fernald, & Ramakrishnan, 2008),although younger men are also working as motorcycle-taxi drivers.There are 2500 families (50% of households) that are beneficiariesof the poverty alleviation program Oportunidades (personal com-munication, Jorge, Health Promoter, July 2008). In this programwomen receive a cash stipend conditional on meeting certainhealth and education co-responsibilities (e.g., vaccination, prenatalcare, keeping children in school).

The marginalization index (very high to very low) is a globalmeasure of social inequity (education, household construction, min-imum salaries, and rural setting), and is used to compare communi-ties in Mexico on relative under-development (INEGI, 2005). Thiscommunity has a high marginalization index: 16% are illiterate, 8%of homes do not have a latrine, 16% are without running water, 39%are without a refrigerator, and 52% have a dirt floor (INEGI, 2005).

Data collection

From February to June 2009, the first author (EM) conductedinterviews and home observations. Although EM is Latin Americanand fluent in Spanish, she was an outsider in the community, soshe worked with the public-health nurse to gain the women’s trustand entry to their homes.

We included non-pregnant women P18 y with child betweenthe ages of 6–18 mo. We did not include infants who had congen-ital abnormalities. We used a convenience, strategic samplingstrategy. We recruited participants from the waiting room at theclinic where the interviews were being conducted, referral fromother women, the public health nurse’s home visits, and her inter-action with members of the community who fit our inclusion cri-teria. Also, midway through recruitment, and based onpreliminary analysis of the interviews, we sampled additional wo-men with 12–18 mo-old children. INSP investigators with qualita-tive research experience in this community suggested that asample size of 30 women would be sufficient for elucidating con-cepts of feeding children.

After completing 10 interviews and home observations, EM re-viewed the interview content before recruiting the next set of 10women. This strategy was repeated until we reached the targetsample size. We completed 31 interviews and reached theoreticalsaturation at about 20 interviews. We excluded two participantsbecause one child was premature, and these children have distinctfeeding patterns, and another interview was incoherent. We con-tinued to interview beyond saturation because we wanted to besure that the last 10 interviews confirmed what women had previ-ously said about feeding children. All women signed informed con-sent and authorized the home observation as well as tape-recording of the interview. Women were informed that this studywas to learn more about how mothers feed their children and fam-ilies. They were also promised confidentiality, so pseudonyms havebeen used here. Ethical approval for this study was obtained fromthe Ethics, Biosecurity, and Research Commissions at INSP and the

Table 1Characteristics of the 29 women included in the analysis.

Characteristic Summary statistic Remarks

Maternal age, y 25.9 ± 5.3a (18, 37)Child age, mo 12.4 ± 4.1 (5, 18)Children P1 y 68%Body Mass Index, kg/m2 28.4 ± 5.0 (17, 37)Women with BMI P30 41%Education, y 8 ± 2.2 (6, 12)Employment, n 7 Selling food: tortillas,

vegetables or fruitGovernment programs, n 7 four received

Oportunidades threereceived Liconsa

Lived with others, n 19 In-laws or parentsMarried, n 26Parity, n 2.2 ± 1.04 (1, 5)Breastfeeding, yes, n 26

a Mean and standard deviation; range in parentheses.

E.C. Monterrosa et al. / Appetite 59 (2012) 377–384 379

Institutional Review Board for Human Participants at CornellUniversity.

Women were interviewed once at the public health clinic in asmall room, and each interview took 60–80 min. Of the 31 womenwho participated in the interview, 27 agreed to the home observa-tion. Women who did not agree reported that their husbands ormother-in-laws were not comfortable having a stranger in theirhome. Observations were scheduled at their convenience aboutone week after the interview, usually from 8:30 am until 2 pm.In previous work in this community, INSP researchers had foundthat this observation schedule improved participation as it was lessburdensome to the families. For the observation, women wentabout her usual affairs: washing clothes by hand, washing stacksof dishes, tiding up the home, preparing and eat the main morningmeal (almuerzo), feeding and taking care of the children, and some-times watching television. On a few occasions, women picked upthe children from school or went to the market. Most womentalked about the positive and negative aspects of being a motherand a wife. These moments of open dialogue and rapport wereused to clarify ideas or further explore other concepts mentionedin the interviews. Field notes were completed as soon as possibleafter each observation.

EM did not stay for the main meal, often served between 2 and4 pm, and she did not observe what happened in the evening whenthe father was likely to be home. The behaviors EM observed athome were similar to those reported at the interview. Althoughthe length of stay in each home was limited, visiting 27 homes pro-vided EM an excellent opportunity to observe knowledge-in-action(Yoder, 1997). Essentially, the home observation helped captureelements about the process of feeding children that may be lessaccessible through discussions (Pelto & Pelto, 1997) and improvedthe trustworthiness of the data.

General analytical strategy

Throughout data collection, EM reviewed the transcripts andmade adjustments in future interviews to capture more detailsabout emerging ideas and behaviors. EM read the transcripts toidentify the major themes about child feeding (first pass). Thethemes that emerged from this first pass were: (a) child-appropri-ate foods and food frequency, (b) food preferences, (c) family foods,(d) and household finances, and (e) feeding advice and familymembers (fathers, grandmothers, mother-in-laws, siblings). Tran-scripts were then coded for these themes in Atlas Ti (v 5.2, GmbH,Berlin) (second pass) using a combination of in vivo codes andpreselected codes. The Query Tool in Atlas Ti was used to lookfor patterns of shared cultural knowledge (pooled informationacross all interviews) to derive the key concepts for child feedingpractices. The second author, GP, helped organize the emergingconceptual framework. Then each interview was examined for fac-tors that influenced child-appropriate foods. In doing so, linksemerged between the framework and events, factors, or actors inthe everyday experiences of these women. A methodologicalmemo that detailed the links was completed for each woman.More detail about deriving the concepts are outlined in the results.We provide a brief summary of the household factors and theirlinks to the children’s diets as a detailed description of their influ-ence on child feeding practices are presented elsewhere (Monter-rosa, 2010).

Results

Although 31 women were interviewed, 29 interviews wereused. The final sample consisted of six normal-weight women(body mass index [BMI] range: 17 to 18 kg/m2), 11 overweight wo-

men (BMI range: 25–29 kg/m2), and 12 obese women (BMI range:30–37 kg/m2) (Table 1). Most women did not have any formalemployment. In this community, it is common for women whomarry to move into their in-laws’ house, and 65% of the sample re-ported living in the same house with her in-laws or her parents.This sample was relatively homogenous in important socio-demo-graphic characteristics, such as education and use of governmentprograms. Also, all women had access to local market and stores,and participants had lived most of their lives in the communityor nearby.

Only three women had stopped breastfeeding; all other womenwere practicing varying degrees of breastfeeding, from on-demandfull breastfeeding to token breastfeeding, which varied by age ofthe child. On-demand full breastfeeding occurred mostly amonginfants 69 mo; of the nine infants 69 mo, seven were fully breast-fed, as mothers had only occasionally provided tastes of food. To-ken breastfeeding was more variable: three infants <12 mo andfive infants P12 mo were fed breast milk at night, at nap timesor when fussy.

The maternal knowledge framework

There are eight basic concepts that underlie complementaryfeeding practices in this community. These are the concepts thatguide women’s explicit and implicit decisions about what to feedtheir children. The concepts and their descriptions are summarizedin Table 2.

Probaditas

Women used the probaditas (tastes of food, try foods) to de-scribe the first time they gave food. Women described probaditasas small amounts of food, which mostly consisted of fruits, vegeta-bles, soups, and broths, although some reported feeding a fortifiedfresh cheese product (n = 4), Danonino (from Danone), and a probi-otic beverage, Yakult (n = 1), and Gerber jarred baby food (n = 2). Ifwomen were eating a food that could be appropriate for the child,the child would get that probadita.

I gave her probaditas because we would eat and sometimes itseemed like she wanted it and I would give her. (Juana, daugh-ter, 16 mo)

The purpose for probaditas was so the infant’s stomach wouldcomfortably adjust to solid foods and progressively eat more. Thisalso helped to prevent gastrointestinal discomfort, empacho, andensure the child accepted foods later.

Table 2The knowledge framework: basic concepts of complementary feeding in a sample of Mexican women.

Concept Description In vivo code Translation

Probaditas Women begin with probaditas ‘‘probaditas’’ ‘‘tastes of food’’ ‘‘try foods’’Prepare foods

separately for thechild

Young children do not eat adult foodsbecause adult foods contain chile

‘‘le preparo aparte’’ ‘‘I prepare [foods] separately [for the child]’’

Child’s readiness toeat solid foods

Child’s level of preparedness to begin eatingsolid food

‘‘dientes’’, ‘‘señas’’,‘‘doctor aconsejó’’

‘‘teeth’’, ‘‘gestures’’,‘‘physician advised’’

Appropriateconsistency

Child foods have an appropriate consistency(soft, semi-liquid, liquid)

‘‘machacado’’, ‘‘pachurrado’’ ‘‘raspadito’’‘‘bien molido’’, ‘‘colado’’, puré’’ ‘‘puro líquidos’’

‘‘finely chopped’’ ‘‘mashed’’ ‘‘scrapped’’‘‘pap’’ ‘‘puree’’ ‘‘just liquids’’

Variety in diet Feeding different foods and varying themethod of preparation

‘‘trato de variarle’’ ‘‘irle cambiando’’ ‘‘try to vary it’’ ‘‘change it’’

Child’s foodpreferences

Preparing the foods the child enjoys eating, sothat the child will eat

‘‘lo que le gusta’’ ‘‘what she likes’’

Money and food cost Lack of money influences decisions aboutwhich foods to prepare

‘‘cuando hay’’, ‘‘cuando tengo’’,‘‘no me alcanza’’

‘‘when there is [money or food]’’,‘‘there isn’t enough [money]’’

Healthiness of foods(positive andnegative)

Positive foods contribute to child health. Thenegative foods could potentially cause illhealth

‘‘frutas, verduras, leche’’ ‘‘cocino con pocoaceite’’, ‘‘churros’’, ‘‘refresco’’, ‘‘el granito lehace daño’’

‘‘fruits, vegetables, milk’’, ‘‘I cook with littleoil’’, ‘‘fried dough’’, ‘‘sodas’’, ‘‘bean can beharmful’’

380 E.C. Monterrosa et al. / Appetite 59 (2012) 377–384

I started [probaditas] at 3 mo almost. I gave him banana. Iwould give him a little bit and like that by 6 mo, he was eatingmore, he was eating things. (Liliana, son, 13 mo)

When he’s small like this [7 mo], we need to give him probad-itas, not much so he doesn’t get empacho. Not to give him alot only three times a day, to try, so his stomach begins toaccept food. (Lidia, son, 7 mo)

Readiness to eat solid foods

Women relied mainly on two sources of information to maketheir decision for when their children were ready for solid foods,the children themselves and health professionals. Twelve womencited presence of teeth and hand or body gestures as cues for start-ing solid foods.

I saw that she wanted to eat, she asked for things. Like if shewas anxious to eat. And I also saw that she had his four teeth,bottom and top, and I tried feeding her. (Liliana, daughter,13 mo)

Advice from health professionals, mostly physicians and a fewnurses, was the other main reason women started offering solidfoods (n = 12). Of the women who received advice from the healthprofessionals on when to start feeding and what foods to give, ninesaid they followed it.

Well, I haven’t fed her anything yet. I saw the doctor and shesaid to start feeding squash. But I haven’t given her that. (Myra,daughter, 5 mo)

Other reasons for starting solid foods were ‘‘baby was still hun-gry after breastfeeding’’ (n = 1), ‘‘away from child for extendedperiods of time’’ (n = 2), ‘‘ready to receive food at 12 mo’’ (n = 1),and ‘‘advice from her mother’’ (n = 1).

Prepare food separately for the child

Women were asked to describe the different type of foods theyprepared for the family, and it was often in response to this ques-tion that the women would clarify, ‘‘for the children or for theadults’’ or where the phrase ‘‘I prepare foods separately for them’’would be used. Women noted that a young child could not eat chile(fruit of the Capsicum plant and used as a spice) and that adults atefoods prepared in salsa (sauce) that contained chile (salsa also con-tains tomatoes and onions). When women prepared these foods insalsa, they also stated to have prepared food separately for her

young children. To ‘‘prepare separately’’ was not only about pre-paring different types of foods but also about serving the samefamily food, without salsa, to the child.

If we eat chile, we prepare separately a broth. If we eat pork wedon’t give him [baby]. When I buy chicken, I make a broth forhim, and for us [chicken] in salsa. (Ana, son, 7 mo)

So that we all eat, a soup, or a chile sauce separate for us[adults]. (Gina, son, 18 mo)

[I don’t give] for example, pork meat, stuffed chiles, or when-ever I make something spicy. (Juana, daughter, 16 mo)

When I make chicken broth, I cut the tortilla into small piecesand add it to the broth. I prepare the broth the same way, buthis, I serve his special for him. (Ana, son, 7 mo)

Appropriate food consistency

When women talked about the foods they introduced first andthe foods they prepare for the young child, the consistency of foodwas clearly discernible in their descriptions. They used that foodattribute to make decisions about what to feed young children.

My mother says we should give food that is mashed, liquids sothat they can eat well. They are accustomed to drinking things.She says I should try to give them natural water, fresh juice. . .

(Susana, son, 16 mo)

[I’ve started feeding] all types of juices, orange juice or what-ever fruit I have. When I make fresh juice I give him some sohe can try. Broths, soups, bean broth. (Lidia, son, 7 mo)

In addition to the liquid or semi-liquid consistencies, womennoted that solid foods should be mashed or finely chopped for chil-dren. They used the word papilla (pap) to describe any food in papform, often making reference to a Gerber-like pap consistency, orto Nutrisano, the fortified milk powder provided by Oportunidadesprogram) available at the health center. Soft foods, such as yogurtand puddings, were also considered appropriate for infants andyoung children. Women discussed how they gradually transitionedchildren from pap or mashed to finger foods, such as cut fruit andpieces of tortilla. Beef and chicken were not offered until well intothe second year of life, when the child had several teeth, a sign thatthe child could safely handle the texture of meats.

When he was 5 mo we gave him the noodle soup mashed. Now Igive him soup, beans [broth], and I gave him the vegetablesfinely diced because he doesn’t bite well. (Tulia, son, 9 mo)

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The mango and apple, I give it to her in pieces because shedoesn’t want it mashed. (Ari, daughter, 12 mo)

I make her a taco and I place it in her hand and she eats it, evenif it is only to tear off pieces [with her mouth] but that’s how shelearns. (Juana, daughter, 16 mo)

Women used the back of the spoon to mash foods or used theedge of the spoon to cut foods into small pieces.

Variety in diet

Women discussed the importance of providing different typesof foods, exposing the child to new foods and establishing goodeating behaviors. Food variety was one mechanism to improveacceptability of foods. As already noted, probaditas were importantfor achieving variety.

We have to give them different foods, teach them to eat more ofeverything, give them varied food. (Ivonne, son, 6 mo)

I give him one day yes, one day no because I vary it. One day it’srice, another day potatoes, another day beans, one other daybroths. The soups are made with pasta. I vary it because eachsoup has a different taste. Sometimes I give elbows, noodle,sometimes letters. (Nadia, son, 17 mo)

Variety in the child’s diet was related to variety in the foodspurchased for the family consumption.

The meats, fish, chicken, vegetables and fruit, beans, lentils, rice,well that’s what we mostly eat. Try to vary it, making it one wayand then another. (Juana, daughter, 16 mo)

Child’s food preferences

What the child did and did not like guided what foods themother offered and how they were prepared. For instance, 11 wo-men stated directly that a soup or broth was the child’s favoritefood. Very few women noted vegetables as a child’s preferred food.Probaditas were also important for ascertaining food preferences.

When I give her what she likes, she eats it, and when I don’t shethrows it. (Juana, daughter, 16 mo)

If I eat fish, I give her to try to see if she will like it. On Sunday Ihad fish and I gave her to try. I use probaditas like that. (Liliana,daughter 13 mo)

Table 3Women’s concepts of positive foods, negative foods, and their rationale.

Rationale

Positive foodsVegetables ‘‘helps children grow’’; ‘‘helps with learning’’Fruit ‘‘helps children grow’’Breast milk ‘‘provides defenses’’Yakult ‘‘it’s good for children’’Milk ‘‘good for their health’’; ‘‘keeps them well

fed’’

Negative FoodsJunk food: churrosa andcandy

‘‘sticks to the stomach’’

Carbonated beverages, Coke ‘‘mal de orin’’, urinary tract infectionsBean ‘‘sticks to the stomach and causes

indigestion’’Oil ‘‘don’t like to use too much’’Pork ‘‘not good’’ for young children; ‘‘heavy’’

a Churros are deep-fried wheat dough sprinkled with cinnamon and sugar.

Money and food costs

Not having enough money was a key consideration for womenin this low-income community. ‘‘When there is money’’, ‘‘some-times there isn’t enough (money)’’ were frequent phrases. Moneyand food costs were an integral part of women’s knowledge aboutchild feeding.

In spite of serious economic constraints, women highly valueddiet quality and had several strategies to provide quality in theirchildren’s diets. Some said they bought ‘‘a little bit of everything’’even if it was expensive. This strategy was mostly reported by wo-men with one child. In households were there were two or morechildren, women adopted other strategies: (a) fed expensive foodsless often, for instance fruits would be provided one day, vegeta-bles another day and meat on yet another, and in cases of severemoney shortages, the adults would not consume these items; (b)substituted the expensive items with cheaper alternatives, or (c)bought cheaper items.

When I have enough money, I prepare [puddings] with milk, ifnot with water. . . I prepare a soup with chicken or at least withhard-boiled eggs. (Myra, daughter, 5 mo)

The fruit, I get it only for my children because I can’t afford tobuy it for us. I wish I could give them fruit everyday but I justdon’t have enough money. I give it to them four times per week.(Carol, daughter, 14 mo)

Well, because I give him a [chicken] bone to suck on, I buy awing or the back. Sometimes, honestly, when I don’t have, Ibuy the saddle, which has more fat, but I take it off. (Graciela,daughter, 12 mo)

I’m buying a lot of bananas. Whatever is cheap. My sister saysthat I give my children too much egg, but it is what is cheapand it goes a long way. (Gina, son, 18 mo)

Healthiness of foods (positive and negative attributes)

As women discussed what to feed children, they made directand indirect references to foods they considered healthy, un-healthy or harmful for their child. We elicited these ideas also byasking ‘‘if you and other women with young children talk aboutfeeding babies, what sort of things would you discuss?’’ The foodsdiscussed positively and negatively as well as the rationale aresummarized in Table 3. The rationale for ‘‘positive’’ foods wasshared by most women. With the exception of Yakult, most womensaid that if they had more money they would feed more of the po-sitive foods. Two women specifically noted wanting to feed moresoups and broths if they had more money.

Seven women discussed ‘‘negative’’ foods. In regard to ’’ junkfoods’’ and carbonated beverages, one woman thought that junkfoods were alright as occasional treats and two other women occa-sionally purchased fruit-flavored sodas. One woman stated that so-das could cause urinary tract problems. Although pork meat wasconsidered not appropriate for young children, two women had gi-ven pork, and one woman noted feeding deli-style ham withscrambled eggs. Some women talked about using little oil in theircooking but did not state why they did so; only one mother talkedabout how rice was ‘‘heavy’’ because it required so much oil duringcooking.

In sum, probaditas, readiness to eat solid foods, appropriate con-sistency, preparing foods separately, variety in the diet, child’s foodpreferences, money and food cost, and healthiness of foods werethe eight concepts in their knowledge framework for how to feedyoung children. This knowledge is needed to interpret the meaning

382 E.C. Monterrosa et al. / Appetite 59 (2012) 377–384

of events, factors, and action of others that together generate cul-turally appropriate behavior. In the following section we providea brief summary of the household factors and their influence oncomplementary feeding.

The children’s diets and the household factors linked to their diets

The diets of infants (<12 mo) consisted mainly of soups andbroths, fruits, and, to a lesser extent, vegetables. After the firstbirthday, dietary variety improved as mothers began to feed chick-en, fish, beef, eggs, milk, yogurt, Danonino (fortified cheese com-mercial product), Yakult, atole (corn-based drink with or withoutmilk), pudding (with or without milk), tortilla, rice, and beans(for a complete description of the children’s diets, see Monterrosa,2010). After 1 y, mothers also reported feeding sweet (e.g., cookies)and savory snacks (e.g., chips), and this was also observed in thehome visits. Table 4 highlights the most common foods fed from6–18 mo.

Across households, variety in the children’s diets was associatedwith household finances, food preferences of other family mem-bers the presence of young children. Advice from other familymembers was important in sharing knowledge and promoting cul-turally appropriate behaviors.

Household finances determined to a large extent the frequencywith which vegetables, chicken, fish, and milk products were pur-chased. Family food preferences affected food purchasing deci-sions. As one woman put it, ‘‘what I eat most is what we [the

Table 4Description of the foods most commonly fed to young children by age category.a

Agecategoryb

Common foodsc

6–8 mo,n = 7

Broths: bean (liquid only) or chickenSoups: prepared mostly from scratch using wheat noodle orriceFruit: apple, banana, pear, grapes [drops of juice squeezeddirectly from the grape into the child’s mouth], GerberVegetables: chayote squash, zucchini squash, potato, carrot,green beans, and spinachAnimal source food: chicken (meat only), egg, Danonino,yogurt, infant formulaCereals and grains: tortilla

9–12 mo,n = 6

Soups: prepared mostly from scratch using wheat noodle orriceBroths: bean (liquid only) or chickenFruit: banana, apple, mango, melons, papaya, guavaVegetables: chayote squash, zucchini squash, potato, carrot,cauliflowerAnimal source food: chicken (meat or chicken wing, foot), egg,yogurt, infant formulaCereals and grains: tortilla, atole (corn-based drink)

13–18 mo,n = 16

Soups: prepared mostly from scratch using wheat noodle orriceBroths (liquid + solid): bean or chickenVegetables: zucchini squash, potato, carrot, broccoli,cauliflower, peas, corn, cabbage, and nopalesFruit: banana, apple, mango, melon, papaya, watermelon,orangeAnimal source food: chicken (meat or chicken wing, foot), egg,yogurt, powdered cow’s milk and fluid milkCereals and grains: tortilla (as an accompaniment or as thebase of a meal), atole, rice, bread, cookies (Marie biscuit)Legumes: beansOther: Yakult (probiotic beverage)

a Food offered at least once per week in each age category. Not all women offeredall foods to child once per week.

b 6–8 mo, solid foods offered as pap or mashed; 9–12 mo, transition from pap tomashed, finger foods, or food that could be finely chopped; 12–18 mo: foods arefinely chopped.

c For fruits and vegetables participants bought mostly what was in season. Fre-quency of infant formula and cow’s milk varied with the degree of breastfeeding.

family] eat’’. If the young child or other young children had partic-ular preferences or aversions, mothers were also less likely to makethese food items. If the woman had other children <5 y old, foodpreparation was made easier by preparing meals that all childrencould eat, so broths and soups were prepared more frequently.

Advice from mothers and mothers-in-law was another mecha-nism through which knowledge was shared and behaviors werereinforced. For example, Ivonne noted, ‘‘when he was 4 mo, mymother said ‘it’s time to start feeding’. That’s mostly what shewould say, to give him the chayote [squash].’’ Advice could alsotake the form of directives about what the child should be consum-ing: ‘‘my mother-in-law, well she sends me to make him his soups,his broths’’.

In summary, household factors influenced the variety of thechildren’s diets because they help structure the environment inwhich mothers could make food choices for her family and youngchild.

Discussion

Using ethnographic methodology, we have identified eight keyconcepts of the maternal knowledge framework for complemen-tary feeding in a Mexican community. We constructed an emicframework to show how maternal knowledge guides meaningfulbehavior and the relationships among the concepts, and how livedsocial realities influence complementary feeding. Maternal knowl-edge frameworks like the ones we present here are rarely made ex-plicit in descriptive studies of complementary diets (Enneman,Hernández, Campos, Vossenaar, & Solomons, 2009), formative re-search (Chaidez, Townsend, & Kaiser, 2011; INSP, 2003) or researchon the psychosocial determinants of complementary feeding (Hor-odynski et al., 2007; Synnott et al., 2007).

In this community, the knowledge about complementary feed-ing can be summarized as follows. Women start feeding solid foodswith probaditas. They feed small amounts of food to introduce newfoods and to avoid illness. A woman knows when the infant isready to start probaditas by being attentive to the infant’s behavior,following a physician’s advice, or listening to the advice of familymembers. Women may use a combination of these strategies to de-cide when to start foods. Once complementary feeding begins inearnest, a woman must prepare foods separately for the child be-cause adult foods should not be fed to young children, particularlyif they contain chile. Child-appropriate, family foods are thosewithout chile and are semi-liquid, liquid (i.e., broths), or soft con-sistency [i.e., eggs, tortilla-based meals (tacos), rice] as those arefoods safe for the young child. As the child’s motor capacities(e.g., chewing and teeth) improve, women transition them to thefamily diet, but those first foods remain appropriate for all youngchildren. A woman must ensure sufficient variety in the child’sdiet, using different methods of preparation and different foods,giving frequently the healthy foods and avoiding the negativefoods, to ensure good growth, development, and to some extenthelp establish good feeding behaviors. Preparing the foods thechild enjoys eating is crucial for food acceptability. Knowledge ofmoney and food costs is important for ensuring a nutritious dietin light of the economic constraints. The goal (i.e., cultural theme)is to feed the child to ensure good nutrition, health, and growth.This knowledge guided practices.

Women offered similar rationale or explanations for feedingtheir children, so the concepts and the cultural theme underlyingchild feeding were shared. The findings on underlying culturaltheme corroborate those of Guerrero et al. (1999) that women inMexico City chose an infant feeding method if they believed it pro-vided good nutrition, health, and improved growth. They alsonoted that these cultural beliefs to be shared to a high degree

E.C. Monterrosa et al. / Appetite 59 (2012) 377–384 383

(Guerrero et al., 1999). Shared cultural knowledge, as seen here,also indicates that complementary feeding is quite prescriptive inthe cultural sense. The cultural prescription is rooted in a logic thatworks to keep children well-nourished and healthy (Sellen, 2007).

Inasmuch as women use knowledge to interpret their livedexperiences and generate behavior, concepts in maternal knowl-edge frameworks are interrelated with material conditions and so-cial environment, especially if these conditions and environmentare important determinants of behavior. For example, the interre-lation is most apparent in the domain of ‘money and food cost,’where persistent economic constraints have likely given rise to acognitive dimension. Physicians and other health professionals—even the presence of the first author at the interview and homeobservation—may strongly reinforce ideas of positive foods as evi-denced by the medical words to describe these foods (e.g., vita-mins, defenses). This food attribute, however, likely evolved fromthe Hot and Cold classification system that is used throughout La-tin America to describe foods and their relationship to disease(Messer, 1981). Health professionals may also emphasize the‘‘readiness to eat solid food’’ domain. The ‘‘prepare foods sepa-rately’’ domain is highly influenced by ideas about what consti-tutes family meals. Food companies also may reinforce the‘‘appropriate consistency’’ domain as evidenced by references toGerber-like consistency and food prepared as pap.

In general, across cultures, grandmothers are crucial for helpingto establish the cultural rules and supporting practices. Similar toour study, Bezner-Kerr, Dakishoni, Shumba, Msachi, and Chirwa(2008) showed that in Malawi paternal grandmothers were keydecision-makers on when to start feeding foods. Guerrero et al.(1999) also reported that mother-in-laws and grandmothers pro-vided a substantial proportion (37%) of the child feeding advice.

Knowledge frameworks also provide women with the concep-tual elements for interpreting their experiences, and for the wo-men in our study, who mostly stayed at home, household factors(i.e., family food preferences, financial constraint, and multiplechildren) influence variety and adequacy of complementary foods.For example, food preferences of the mother and other siblingswere discussed in the context of food purchases, which were re-flected to some degree in the child’s diet. In Morelos, Mexico,researchers also reported that the family diet and food preferencesof family members influenced how often flesh foods were fed tothe child (INSP, 2003). Similar findings on maternal food prefer-ences and complementary foods have been reported by others inthe U.S. (Birch & Fisher, 1998; Hart, Raynor, Jelalian, & Drotar,2010), U.K. (Robinson et al., 2007) and Mexico (Mennella, Turnbull,Ziegler, & Martinez, 2005).

Household financial constraints limited household food avail-ability. Knowledge of food costs and money was used to devisestrategies (e.g., buying cheaper alternatives more frequently ormore expensive items less frequently) that achieved sufficientquantities of healthy foods distributed equitably among youngchildren in the home. The management of household food re-sources to shield children from insufficient food have been re-ported in food-insecure households in the U.S. (Radimer, Olson,Greene, Campbell, & Habicht, 1992). When financial resourcesare limited, it is less likely that young children will receive a vari-ety of fruits, vegetables, and iron-rich foods (e.g., meat) becausethese are more expensive than egg, pasta or other cooking vegeta-bles (e.g., tomato and onion).

It is plausible that similar concepts exist among women livingin similar social and ecological environments to the women inour study (Sanjur, 1995). The cultural appropriateness of liquid-based foods has been also reported in Latin America. Ennemanet al. (2009) found that within a 24-h period about half of the fooditems offered to Guatemalan infants 6–12 mo were soups, stews,and liquid-based foods, with no statistically significant differences

between urban and rural settings. In a sample of Afro-Colombianwomen, 75% reported soups as the first food (Alvarado et al.,2005). Concepts mentioned by participants in our study, such aschild’s food preferences, variety, and readiness to feed solid foods(using infant cues and advice from the doctor), have also been re-ported by mothers of Mexican origin living in California as impor-tant determinants of infant feeding practices (Chaidez et al., 2011).That similar concepts were discussed by participants in our studyas by Mexican women living �7 y in the US suggests that we mustexamine how changes to the social and physical environmentinfluence both maternal knowledge frameworks and the processof feeding young children.

There are some limitations to the inferences that can be drawnfrom our sample. Only three women in this study were not breast-feeding at the time of data collection. Although behaviors would bedifferent among women who are not breastfeeding, it is likely thatthe knowledge framework would be similar to the one describedhere. Also, one would expect knowledge framework to be differentamong women with more education. We do not know to what ex-tent women over-reported (or engaged in) positive behaviors andunderreported negative behavior. Analysis of the field notes takenduring home observations, which were conducted one week afterthe interview, did not reveal behaviors that were different fromthose articulated in the interviews. Consistency between the inter-view and observational data suggests that the data are credible anddependable (Lincoln & Guba, 1985). Moreover, our results are con-sistent with what has been reported in Morelos and Mexico City(INSP, 2003) and by Mexican-born mothers living in the U.S (Chai-dez et al., 2011). The feeding patterns described here are similar tonational-level data in that children in low-income households donot regularly consume non-human milk, legumes, and flesh foods(González-Cossío et al., 2006). It is possible, however, that womenare more likely to discuss behavior and ideas that are normativerather than non-normative. Other ways to elucidate non-norma-tive elements and behaviors would be to protract the observationalperiod (Yoder, 1997).

A few women (n = 4, 14%) in this study said they were beneficia-ries of the Oportunidades program, and these participants did notprovide different responses to our questions. The nutrition educa-tion component of this program, which aims to improve IYCF, mayreinforce concepts of healthy and unhealthy foods, consistency(e.g., pap, puree, mashed), and variety of foods. With this study de-sign we cannot say how or even if Oportunidades has changed thematernal knowledge framework. Further research is needed toexamine how nutrition education generates new knowledge orshifts existing knowledge frameworks.

We did not investigate in detail the role of the food system oncomplementary feeding practices. The women in our study pur-chased food from the local market to prepare family meals ‘‘fromscratch.’’ Processed foods, such as dairy products and pasta, wereavailable and were utilized. It is likely that food companies use ele-ments of the maternal knowledge framework to drive food choices,but they may also shift concepts in ways not yet revealed. Thismerits further analysis given that most women in this study hadaccess to television and are exposed to brand marketing.

Conclusion and implications for future research

This study provides evidence that women have highly orga-nized knowledge about child feeding. Theirs is a logical knowledgeframework, based on the cultural theme of ensuring good health,nutrition, and growth. The eight concepts in their knowledgeframework provide an explanation for why mothers mostly feed li-quid and semi-liquid savory foods, and fruits, with few vegetables,meats, and legumes. Our research also reveals the centrality of theyoung child in feeding decisions (e.g., preferences and cues), and

384 E.C. Monterrosa et al. / Appetite 59 (2012) 377–384

the foods that form the base of the complementary diet (e.g., soupsand broths).

The study underscores the primacy of knowledge in comple-mentary feeding. Knowledge frameworks are the cognitive scaf-folding for what and how to feed young children, so knowledgeframeworks are fundamental for understanding food choice. Ac-tors, such as physicians and grandmothers, help reinforce or sus-tain concepts and behaviors. In the study community, householdfactors (e.g., material constraints, food preferences) structure thefood environment (i.e., important for what young children couldbe fed) in which mothers make feeding choices. The distinction be-tween the cultural and household domains has implications forintervention design. If we, for example, intervene with cash trans-fers, food rations, or home-fortification with micronutrient packetsto improve diet quality, we may improve some dimensions (e.g.,more milk or fruit) but not others (e.g., meat and solid foods untilchild is old enough to chew, not giving vegetables because thechild dislikes them). Thus, intervening on household factors is nec-essary but insufficient for improving complementary feeding atscale.

Maternal knowledge frameworks are foundational to any workon behavior change. The methodology we used in this study is fea-sible within the usual budgetary and time constraints of interven-tion development research. In-depth interviews during whichwomen discuss their experiences with child feeding (in contrastto asking women why they do what they do or focusing on a nutri-tion problem), home observations to elucidate the tacit elements ofcomplementary feeding and the knowledge-in-action (Yoder,1997), and a qualitative analysis of the data that yields an emicframework, as well as a summary of the psychosocial dimensionsof maternal behavior, are not difficult to organize and execute.These are the foundation for creating culturally relevant and effec-tive, large-scale programs. Building from the resulting knowledgeframework, formative research could then focus on programmaticelements, using group discussions to develop targeted messagesand identifying barriers to effective program delivery.

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