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Factors Predicting Consumption of Fonio Grain (Digitaria exilis) among Urban Malian Women of Reproductive Age

Published:March 07, 2011DOI:https://doi.org/10.1016/j.jneb.2010.03.008

      Abstract

      Objective

      To identify factors influencing intention to consume an indigenous nutritious grain, fonio (Digitaria exilis), among women in Mali.

      Design

      A cross-sectional questionnaire survey based on the Theory of Planned Behavior and the Health Belief Model.

      Setting and Participants

      One hundred and eight women (31.5 ± 10.5 years), randomly selected by a 3-stage cluster sampling, Bamako, Mali.

      Main Outcome Measures

      Model constructs scores, intention to consume fonio, and fonio consumption.

      Analysis

      Correlation and multiple regression, Wilcoxon signed rank and Mann-Whitney tests for score comparison.

      Results

      Attitudes toward behavior (β = .32, P < .05) was the best predictor of intention to consume fonio, which was significantly correlated with fonio consumption (rho = .78, P < .001). Health value (β = .23, P < .05) was a significant predictor of health behavior identity, which was significantly correlated with attitudes toward behavior (rho = .67, P < 0.001) and perceived barriers (rho = .33, P < .001). The latter formed a significant interaction term between intention and behavior (β = -.72, P < .05).

      Conclusions and Implications

      Fonio consumption could be increased in Bamako through stimulation of positive attitudes, changing men's beliefs, influencing family and neighbors' opinions, and improving the processing and the skills of women who prepare fonio.

      Key Words

      Introduction

      Sorghum and millet are among the world's most important food crops being the main sources of protein and energy,
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      especially for inhabitants of the semi-arid tropics. In Mali, sorghum, millet, maize, rice, and fonio are traditionally common cereals that provide the basis for a daily meal in many households.
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      Fonio (Digitaria exilis) is considered one of the oldest West African indigenous cereals.
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      • Burton G.
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      Fonio (Acha).
      Up to 250,000 tons of fonio are produced annually on more than 380,000 hectares,
      • Cruz J.F.
      Fonio: a small grain with potential.
      and its contribution to food security has been suggested.
      • Vodouhè S.R.
      • Achigan-Dako E.G.
      Digitaria exilis (Kippist) Stapf.
      Fonio resembles Te'f (Eragrostis tef), a traditional cereal cultivated in Ethiopia. Te'f and fonio have some similarities in structural and physicochemical properties.
      • Jideani I.A.
      Traditional and possible technological uses of D. exilis (acha) and D. Iburua (iburu): A review.
      The potential for production of fonio in West Africa is high, because it performs better than other cereals under conditions of drought and low soil fertility, and it is less susceptible to damage by pests during storage.
      • Irving D.W.
      • Jideani I.A.
      Microstructure and composition of Digitaria exilis Stapf (acha): a potential crop.
      In countries like Burkina Faso, Guinea, Senegal, Mali, and Nigeria, fonio is a staple food, especially for communities in mountainous areas.
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      Fonio (Acha).
      Its potential for reducing human misery during “hungry times” is valuable because some varieties have a very short growing cycle and are ready to harvest before all other grains. Moreover, when other cereals are scarce because of a failing harvest, fonio consumption is high.
      • Vietmeyer N.
      • Borlaugh N.
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      • Burton G.
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      Fonio (Acha).
      Nutritionally, fonio is regarded as a rich source of energy during the food shortage season.
      • Vietmeyer N.
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      • Axtell J.
      • Burton G.
      • Harlan J.
      • Rachie K.
      Fonio (Acha).
      The food composition table of Mali indicates fonio as the cereal with the highest content of calcium (41 mg/100 g dry matter) compared to the other cereals, and it has the second-highest concentration of protein (7.1 mg/100 g dry matter) and iron (8.5 mg/100 g dry matter) after sorghum (11 mg/100 g dry matter for both protein and iron).
      • Barikmo I.
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      Food Composition Table for Mali. Oslo.
      Fonio is also an excellent source of methionine, cysteine, and leucine, the concentrations of which are slightly higher than those defined for the Food and Agriculture Organization reference protein.
      • Temple J.V.
      • Bassa D.J.
      Proximate chemical composition of Acha (Digitaria exilis) grain.
      Fonio species contain less polyphenols than sorghum,
      • Ekpenyong T.E.
      Effect of cooking on polyphenolic content of some Nigerian legumes and cereals.
      hence the high digestibility of protein observed in fonio.
      • Jideani I.A.
      • Owusu Apenten R.K.
      • Muller H.G.
      The effect of cooking on proteins of acha (Digitaria exilis) and durum wheat.
      Fonio is among the world's best-tasting cereals and has a high diversity of uses in human consumption.
      • Vietmeyer N.
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      • Axtell J.
      • Burton G.
      • Harlan J.
      • Rachie K.
      Fonio (Acha).
      In many African countries, fonio is traditionally cooked as couscous, various porridges and dishes, and local beverages.
      • Vodouhè S.R.
      • Achigan-Dako E.G.
      Digitaria exilis (Kippist) Stapf.
      • Adoukonou-Sagbadja H.
      • Dansi A.
      • Vodouhe R.
      • Akpagana K.
      Indigenous knowledge and traditional conservation of fonio millet (Digitaria exilis, Digitaria iburua) in Togo.
      Also, fonio has been used for bakery products such as cakes, doughnuts, and cookies, and it has been suggested as a substitute for semolina (a wheat product used to make pasta).
      • Jideani I.A.
      Traditional and possible technological uses of D. exilis (acha) and D. Iburua (iburu): A review.
      Fonio has a great religious and sociocultural importance for its producers in many West African communities.
      • Vietmeyer N.
      • Borlaugh N.
      • Axtell J.
      • Burton G.
      • Harlan J.
      • Rachie K.
      Fonio (Acha).
      • Adoukonou-Sagbadja H.
      • Dansi A.
      • Vodouhe R.
      • Akpagana K.
      Indigenous knowledge and traditional conservation of fonio millet (Digitaria exilis, Digitaria iburua) in Togo.
      • Portères R.
      Les céréales mineures du genre Digitaria en Afrique et en Europe [Minor cereal Digitaria species in Africa and Europe].
      In Senegal, Mali, Guinea, Burkina Faso, and Togo, fonio is reserved particularly for chiefs, royalty, and special occasions like Ramadan for Muslims.
      • Adoukonou-Sagbadja H.
      • Dansi A.
      • Vodouhe R.
      • Akpagana K.
      Indigenous knowledge and traditional conservation of fonio millet (Digitaria exilis, Digitaria iburua) in Togo.
      • Portères R.
      Les céréales mineures du genre Digitaria en Afrique et en Europe [Minor cereal Digitaria species in Africa and Europe].
      For some traditional communities in Togo, fonio is the most important ingredient in women's initiation ceremonies, weddings, and for the traditional baptism of newborn children. In some communities, fonio is believed to help prevent blood clotting after women give birth,
      • Adoukonou-Sagbadja H.
      • Dansi A.
      • Vodouhe R.
      • Akpagana K.
      Indigenous knowledge and traditional conservation of fonio millet (Digitaria exilis, Digitaria iburua) in Togo.
      and fonio porridge is recommended for breastfeeding women to stimulate milk production.

      Vodouhe SR, Zannou A, Achigan Dako EG, eds. Actes du premier atelier sur la diversité génétique du fonio en Afrique de l'Ouest [Proceedings of the first workshop on genetic diversity of fonio (Digitaria exilis) in West Africa]. Guinea Conakry, August 4-6 1998. Rome, Italy: IPGRI; 2003:36-41.

      The grain is also reported to be easy to digest.
      • Cruz J.F.
      Fonio: a small grain with potential.
      One of the objectives of the Plan of Action of the Food World Summit 1996 was to reduce by half the number of undernourished people before the year 2015.

      Vodouhe SR, Zannou A, Achigan Dako EG, eds. Actes du premier atelier sur la diversité génétique du fonio en Afrique de l'Ouest [Proceedings of the first workshop on genetic diversity of fonio (Digitaria exilis) in West Africa]. Guinea Conakry, August 4-6 1998. Rome, Italy: IPGRI; 2003:36-41.

      The importance of the production and consumption of traditional underused crops with good nutritional value, which have been abandoned in favor of commercial crops, was highlighted among the recommended strategies to ensure food security in West African households.

      Vodouhe SR, Zannou A, Achigan Dako EG, eds. Actes du premier atelier sur la diversité génétique du fonio en Afrique de l'Ouest [Proceedings of the first workshop on genetic diversity of fonio (Digitaria exilis) in West Africa]. Guinea Conakry, August 4-6 1998. Rome, Italy: IPGRI; 2003:36-41.

      • Morón C.
      Food-based nutrition interventions at community level.
      From a nutrition perspective, underused crops such as fonio could increase the availability of energy and nutrients and provide a balanced diet composition, improving food security in low-income rural and urban households. Moreover, fonio can be cultivated on small family farms with minimum costs of water and fertilizers, in land not appropriate for other crops. Therefore, small producers and women may obtain economic benefits from these income-generating activities.
      • Morón C.
      Food-based nutrition interventions at community level.
      During the past 10 years, collaborative efforts have been made to make fonio more competitive in markets in terms of quality and price, by domesticating the seeds, and by improving the grain processing techniques in small companies and women's groups through the modernization of existing equipment and the development of new equipment.
      • Cruz J.F.
      Fonio: a small grain with potential.
      Modern small-scale processing industries for ready-to-cook products have been developed.
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      Despite these efforts, fonio is still underused and its consumption is low in urban areas. In urban areas in Mali, fonio accounts for less than 1% of the cereals eaten, and the average consumption is between 0.5 kg and 1.0 kg per person annually.
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      To date, limited research has indicated that difficult post-harvest processing, a time-consuming cooking process, and the high-cost of fonio products compared to other cereals like maize, rice, and millet are the main factors explaining low consumption of fonio in urban areas.
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      However, social factors and cultural beliefs can also influence food choice and consumption patterns.
      • Den Hartog A.P.
      • van Staveren W.A.
      • Brouwer I.D.
      Food habits and consumption in developing countries: Manual for field studies.
      To increase the consumption of fonio as a staple food item in urban areas, there is a need to identify social cognitive factors that may positively or negatively influence its consumption, especially in urban contexts. Also, the interrelationships among the potential factors and the consumption of fonio are important issues to be clarified in the process of enhancing production and consumption of a crop that could contribute to household food security in both rural and urban areas.
      The Theory of Planned Behavior (TPB)
      • Ajzen I.
      The Theory of Planned Behavior.
      • Fishbein M.
      • Ajzen I.
      Belief, attitude, intention and behavior: an introduction to theory and research (reviewed work by RJ Hill).
      and the Health Belief Model (HBM)
      • Janz N.
      • Becker M.H.
      The Health Belief Model: a decade later.
      have been used to examine factors influencing consumption behavior.
      • Nejad L.M.
      • Wertheim E.H.
      • Greenwood K.M.
      Comparison of the Health Belief Model and the Theory of Planned Behavior in the prediction of dieting and fasting behavior.
      • McClenahan C.
      • Shevlin M.
      • Adamson G.
      • Bennett C.
      • O'Neill B.
      Testicular self-examination: a test of the Health Belief Model and the Theory of Planned Behavior.
      According to the TPB, behavior is determined mainly by a related intention. Behavioral intention is established based on behavioral attitudes, subjective norms, and perceived behavior.
      • Ajzen I.
      The Theory of Planned Behavior.
      • Fishbein M.
      • Ajzen I.
      Belief, attitude, intention and behavior: an introduction to theory and research (reviewed work by RJ Hill).
      The HBM is a health-specific model, which suggests that health behaviors are the result of a set of core beliefs.
      • McClenahan C.
      • Shevlin M.
      • Adamson G.
      • Bennett C.
      • O'Neill B.
      Testicular self-examination: a test of the Health Belief Model and the Theory of Planned Behavior.
      Sun et al suggested a new model based on the combination of the TPB and the HBM in their study on variables that significantly predict intention to consume iron-fortified soy sauce in rural and urban areas of China.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      This new model consists of 12 constructs distributed within internal and external factors (Figure 1).
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      • Koelen M.
      • van den Ban A.
      Health Education and health promotion.
      Perceived susceptibility is one's subjective perception of the risk of contracting a health condition, and perceived severity expresses the feelings concerning the seriousness of contracting an illness or leaving it untreated. Health value represents the importance of the health consequences of the disease. Perceived barriers are the beliefs about negative aspects of the behavior, whereas attitudes toward behavior are the positive or negative evaluation of the consequences of the behavior and its importance. Health behavior identity reflects whether the person thinks that performing the behavior is a good thing to do. External control beliefs represent one's perceived ability to perform the behavior, and cues to action are external triggers that stimulate action to perform the behavior. Subjective norms reflect what others think the individual should do and the individual's motivation to comply. In the Attitude-Social Influence-Self Efficacy model,
      • De Vries H.
      • Dijkstra M.
      • Kuhlman P.
      Self-efficacy: the third factor besides attitude and subjective norm as a predictor of behavioral intentions.
      the perceived barriers in internal factors are expected to be an interaction term in the relationship between intention and behavior. This relationship was added to the original model of Sun et al in the present study.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      Figure thumbnail gr1
      Figure 1Combined Health Belief Model and Theory of Planned Behavior based on Sun et al,
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      with Spearman correlation coefficients between constructs. ∗P < 0.05; ∗∗P < 0.01.
      Using the combined models of the TPB and HBM, this study seeks to identify factors influencing the consumption of fonio among women of reproductive age in urban areas in Mali.

      Methods

      Participants and Sampling

      In total, 108 apparently healthy women of reproductive age (15-49 years old) belonging to one Malian sociolinguistic group were randomly selected from 108 households in 12 quarters of Bamako, using a 3-stage cluster sampling, as described by the United Nations Children's Fund.
      UNICEF
      Monitoring the Situation of Children and Women: Multiple Indicator Cluster Survey Manual 2005.
      Households were selected using the random walk method,
      • Gibson R.S.
      • Ferguson E.L.
      An Interactive 24-hour Recall for Assessing the Adequacy of Iron and Zinc Intakes of Developing Countries. HarvestPlus Technical Monograph 8.
      and all eligible women from the selected households were listed. From this list, 1 woman was randomly selected in each household for the questionnaire survey. The main selection criteria were willingness to participate and basic knowledge of fonio products as food. When a selected woman did not fulfill the selection criteria, another woman in the same household was selected. Almost all selected women met the selection criteria.
      To identify the items of the model, an attribute-pile sort (APS) study was conducted with 26 key informant women, randomly selected from the previously described list of eligible women based on their willingness to participate, excluding those selected for the main study. Verbal agreements were obtained from the local leaders of the quarters, the heads of households, and the women before starting the survey. The study is part of a larger project aiming at upgrading the quality and competitiveness of fonio and thereby improving the livelihoods of the stakeholders of the marketing system.
      • Cruz J.-F.
      Upgrading quality and competitiveness of fonio for improved livelihoods in West Africa. First year activity report. INCO FONIO, Specific International Scientific Cooperation Activities.
      One objective of the project is to determine the mean nutrient intake and nutritional status of the women of reproductive age in Bamako and the importance of fonio in the dietary pattern. The proposal of the whole survey was approved by the Ethical Committee of the National Institute of Public Health Research of Mali.

      Food APS Study

      The food APS study was conducted in 3 steps: pile sorting, food difference, and food attributes, as described in Blum et al.
      • Blum L.
      • Pelto P.
      • Pelto G.
      • Kuhnlein H.
      Community Assessment of Natural Food Sources of Vitamin A - Guidelines for an Ethnographic Protocol.
      The food groups of the Mali food composition table were used for the pile sorting.
      • Barikmo I.
      • Ouattara F.
      Food Composition Table for Mali. Oslo.
      The food difference method was based on comparison of fonio with rice and millet. The food attributes method was applied only for fonio and fonio products. The women were asked to describe 3 main attributes: (1) the outcomes (advantages and disadvantages) expected when consuming fonio products; (2) the people and the information sources that would enhance their fonio consumption; and (3) the factors that would limit their consumption of fonio.

      Questionnaire

      The questionnaire consisted of 76 items identified by a literature search and the APS study. The items were categorized according to the 12 constructs of the model described by Sun et al (Figure 1).
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      The maximum number of questions per construct was 20 (perceived barriers). External control beliefs had only 1 question. Items about iron deficiency and diabetes were introduced in background and perception constructs, because relationships were expected between these items and fonio consumption based on the answers of the women during APS study. Behavioral intention and behavior are the intention to consume fonio and fonio consumption, respectively. Sociodemographic characteristics were recorded as well. The questionnaire was translated into French and Bambara (the most common local language) to ensure that locally used terms for iron in food, iron-rich food, iron deficiency, and diabetes were used. Correctness of the translation was checked with back-translation into English and French, respectively. To ensure that questions were comprehensible for the women and that they were stated in a standardized way by the interviewers, the questionnaire was pretested among 10 women who were different from those participating in the research. No change to the questionnaire was necessary after the pretest.

      Variable Measurements

      The variables were measured at the respondents' homes through structured interviews carried out by well-trained local female assistants (native French and Bambara speakers) based on the questionnaire. To ascertain that the women understood the terms “diabetes,” “iron in food,” and “anemia,” they were asked if they had heard about these terms, and whether they could give an example of food rich in iron before starting the interviews. No women were removed from the study because all of them were aware of the terms. All questions, except for those related to sociodemographic characteristics, were reflected as statements, and the women were asked to indicate their level of agreement using a 5-point Likert response scale, ranging from strongly disagree to strongly agree. To ensure that respondents understood the Likert scale well, an example question not related to fonio was used to clarify the response scale before each interview. For intention to consume fonio and fonio consumption, a different answer scale was used: no consumption, once a month, 2-3 times a month, once a week, and 2 or more times a week.
      The items of most constructs were scored from 1 to 5. However, the items of 2 constructs (attitude toward behavior and subjective norms) consisted of pair questions (behavioral beliefs and evaluation of beliefs, and normative beliefs and motivation to comply, respectively). The scores of the behavioral and normative beliefs ranged from -2 to 2, and scores of the evaluation of beliefs and motivation to comply ranged from 1 to 5. The scores of the pair questions were then multiplied to derive 1 score for each item. This process resulted in a score range of -10 to 10 for each item. For each respondent, the scores within a construct were added, to derive a total score per construct.

      Data Analysis

      Descriptive statistics were performed to examine sociodemographic characteristics of the women, and to calculate the median scores of the constructs. Multiple item constructs were tested for reliability of the questionnaire and internal consistency using Cronbach α and item-total correlation.
      • Field A.
      Discovering statistics using SPSS.
      The items within a construct were regarded as consistent when Cronbach α was approximately 0.80 or higher and the corrected item-total correlation of all items in a construct was higher than 0.30.
      • Field A.
      Discovering statistics using SPSS.
      The Wilcoxon signed rank test was used to compare the scores of intention to consume fonio and fonio consumption and to test whether the subjects significantly changed their response in one direction (ie, score intention > score behavior). A Mann-Whitney test was used to examine whether the scores of women with a high intention and those with a low intention to consume fonio were significantly different. Spearman's correlation (rho) was used to test the bivariate association within constructs. Multiple linear regression analyses were performed to examine the contribution of the constructs to intention to consume fonio, and to assess whether the perceived barriers were a significant interaction term in the relationship between intention to consume fonio and fonio consumption. All models were adjusted for age, education, and interviewer. Overall, statistical tests were 2-tailed, and P values < .05 were considered statistically significant. All statistical analyses were performed using SPSS (version 12.0.1, SPSS Inc., Chicago, IL, 2003).

      Results

      The mean age of the women was just over 30 years, and 15% of the respondents were adolescents (15-18 years old). The illiteracy rate was 29%, whereas 17% reached secondary school and higher. Approximately half the women (46%) went to primary school, but not all had completed the education program. Two-thirds of the women were married, and 34% had more than 3 children. One-third of them had no children. Two-thirds of the women earned an income, mainly by commerce activities (Table 1).
      Table 1Sociodemographic Characteristics of the Women (n = 108)
      CharacteristicsPercentage
      Age
       15-18 years14.8
       19-34 years46.3
       35-49 years38.9
      Education
       Illiterate28.7
       Primary school
      Some of the subjects did not complete the education program.
      46.3
       Islamic school
      Some of the subjects did not complete the education program.
      8.3
       Secondary school or higher
      Some of the subjects did not complete the education program.
      16.6
      Ethnic group
       Malinké21.3
       Bambara18.5
       Peulh12.0
       Other (Sarakolé, Senofo, Bamanan, etc.)48.1
      Marital status
       Married67.3
       Separated2.9
       Unmarried26.9
       Widow2.9
      Number of children
       None33.0
       1-332.9
       4-1134.1
      Income-generating activities66.7
      Note: A household is considered as a group of persons who sleep and eat together.
      a Some of the subjects did not complete the education program.
      Cronbach α coefficients ranging from 0.77 to 0.95 demonstrated high reliability of the multiple item constructs (Table 2). Median scores for all constructs ranged from 4 (external control beliefs) to 70 (perceived barriers). The high value of median scores in comparison to the range of possible scores showed that most women tended to agree with the statements.
      Table 2Internal Consistency and Median Scores of the Constructs (n = 108)
      ConstructsNumber of ItemsCronbach αMedian25th-75thRange
      Range refers to the possible scores for each variable.
      Knowledge12.865046-5512, 60
      Perceived susceptibility8.773227-348, 40
      Perceived severity14.886156-6514, 70
      Health value7.893331-357, 35
      Health behavior identity2.9598-102, 10
      Perceived barriers20.897059-7920, 100
      Attitudes toward behavior12.936748-104-120, 120
      External control beliefs1-42-51, 5
      Cues to action10.874038-4310, 50
      Subjective norms8.923427-50-120, 120
      Intention1-
      Behavior1-
      a Range refers to the possible scores for each variable.
      Almost 40% of the women had consumed fonio at least once a week in the last month, whereas more than 50% had the intention to consume fonio once or more a week. About 5% did not consume fonio in the past month, and 10% had no intention to consume fonio in the next month (Figure 2). Intention to consume fonio was highly correlated with fonio consumption (rho = .78, P < .001; Figure 1). The Wilcoxon signed rank test showed that more than 50% of the women had the same scores on intention to consume fonio and fonio consumption. In case of differences, the score on intention to consume fonio was significantly higher than fonio consumption (P < .001; data not shown).
      Figure thumbnail gr2
      Figure 2Intention to consume fonio in the coming month, and fonio consumption of the last month (n = 108).
      All mean scores of the items within attitudes toward behavior were positive for both the low- and high-intention groups, indicating that the general evaluation of the consequences of fonio consumption was positive in both groups. The Mann-Whitney test for differences between the 2 groups showed that the items' taste, swelling during cooking, nutritional content, health benefits, weight, and treatment of diseases were more important for the high-intention group (P < .05) than for the low-intention group (data not shown). The mean scores of subjective norms were also positive. The husband's opinion was more important for the high-intention group than the low-intention group (P < .05; data not shown).
      Most constructs were significantly correlated with intention to consume fonio, except for perceived barriers, health behavior identity, and cues to action (Figure 1). Significant correlations were found between background and perception of the respondents and health behavior identity, with knowledge and perceived susceptibility showing the strongest correlation (rho ≥ .5, P < .01). Concerning the constructs within “belief and attitude,” health behavior identity was significantly correlated with perceived barriers (rho = .33, P < .001) and attitudes toward behavior (rho = .67, P < .001). This latter construct showed a significant correlation with intention to consume fonio (rho = .29, P < .01). From the external factors, subjective norms (rho = .26, P < .01) and control beliefs (rho = .25, P < .05) showed significant correlations with intention to consume fonio (Figure 1).
      The relative contribution of the variables to behavior is shown in Table 3. Roughly 66% of the variance in fonio consumption could be explained by intention to consume fonio and perceived barriers (Model 4). Only 5% of the variance in intention to consume fonio could be explained by “belief and attitude,” of which attitudes toward behavior was the only significant predictor (Model 2; standardized β = .32, P < .05). The variables within “background and perception” accounted for 34% of the variance in health behavior identity, where only health value was a significant predictor (Model 1; standardized β = .23, P < .05). Subjective norms from the external factors seemed to be the best predictor for intention to consume fonio (standardized β = .28, P < .05, not shown in the table), but significance disappeared after adjusting for age, education, and interviewer (Model 3). In Model 4, perceived barriers were a significant interaction term (standardized β = -.72, P < .05) in the relation between intention to consume fonio and fonio consumption. In the high-barrier-group (score on perceived barriers > 70, n = 54), the association between intention to consume fonio and fonio consumption was lower (rho = .69, P < .001) compared to the low-barrier group (score on perceived barriers ≤ 70, n = 54, rho = .87, P < .001).
      Table 3Predictors of Health Behavior Identity (Model 1), Intention to Consume Fonio (Models 2 and 3), and Fonio Consumption (Model 4) Among Women of Reproductive Age in Mali (n = 108)
      Models
      All models are adjusted for age, education, and interviewer effect
      Standardized βPR2Adjusted R2
      Model 1
      Dependent variable: health behavior identity0.390.34
      Knowledge.22.09
      Perceived susceptibility.08.47
      Perceived severity.19.13
      Health value.24
      Standardized β for these variables were significant (P < .05).
      .01
      Model 2
      Dependent variable: intention to consume0.110.05
      Health behavior identity.03.79
      Perceived barriers-.07.50
      Attitudes toward behavior.32
      Standardized β for these variables were significant (P < .05).
      .02
      Model 3
      Dependent variable: intention to consume0.120.07
      External control beliefs.19.07
      Cues to action-.01.92
      Subjective norms.25.07
      Model 4
      Dependent variable: fonio consumption0.670.66
      Age.15.01
      Perceived barriers.34.05
      Intention to consume fonio1.39.06
      Perceived barriers - intention to consume fonio-.72
      Standardized β for these variables were significant (P < .05).
      .04
      a All models are adjusted for age, education, and interviewer effect
      b Standardized β for these variables were significant (P < .05).

      Discussion

      The core objective of this study was to identify factors influencing the consumption of fonio among women of reproductive age in urban areas in Mali, using the adjusted model of Sun et al.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      Intention to consume fonio was a good predictor of fonio consumption among women of reproductive age. A greater intention to consume fonio was directly associated with positive attitudes and through these attitudes, the intention was indirectly influenced by health behavior identity. The latter was associated with health value. Finally, the association between intention and behavior was lower when perceived barriers were higher.
      The present study confirmed the results of previous studies stating that behavior is mainly determined by a related intention. Intention accounted for 66% of the variance in the behavior in this study. No similar previous studies on fonio or other cereals has been reported to allow comparison, but the predictive power of behavior in this study was higher in comparison with previous studies using the TPB model.
      • Rah J.H.
      • Hasler C.M.
      • Painter J.E.
      • Chapman-Novakofski K.M.
      Applying the Theory of Planned Behavior to women's behavioral attitudes on and consumption of soy products.
      • Kim K.
      • Reicks M.
      • Sjoberg S.
      Applying the Theory of Planned Behavior to predict dairy product consumption by older adults.
      • Blanchard C.M.
      • Fisher J.
      • Sparling P.B.
      • et al.
      Understanding adherence to 5 servings of fruits and vegetables per day: a Theory of Planned Behavior perspective.
      The proportion of women who intended to consume fonio once a week was higher than those consuming fonio once a week in the past month, indicating the potential role of a nutrition education program for promoting the consumption of fonio in urban areas. Increasing fonio consumption in urban areas may strengthen livelihoods of the women who develop modern small-scale processing industries for ready-to-cook fonio, while contributing to energy supply for households especially during the food shortage season.
      Concerning the internal factors, the study showed that attitude measures were the best predictor of behavioral intention, confirming the findings of Nejad et al.
      • Nejad L.M.
      • Wertheim E.H.
      • Greenwood K.M.
      Comparison of the Health Belief Model and the Theory of Planned Behavior in the prediction of dieting and fasting behavior.
      The most important items reported within positive attitudes were good taste, pleasantness in the mouth, easy digestibility, healthfulness, nutritious quality, meal diversification, contribution to weight maintenance, and appetite stimulation. Those beliefs were also reported in previous studies.
      • Sidibe A.
      Le fonio au Mali [Fonio in Mali].
      • Vietmeyer N.
      • Borlaugh N.
      • Axtell J.
      • Burton G.
      • Harlan J.
      • Rachie K.
      Fonio (Acha).
      • Cruz J.F.
      Fonio: a small grain with potential.
      • Vodouhè S.R.
      • Achigan-Dako E.G.
      Digitaria exilis (Kippist) Stapf.
      • Adoukonou-Sagbadja H.
      • Dansi A.
      • Vodouhe R.
      • Akpagana K.
      Indigenous knowledge and traditional conservation of fonio millet (Digitaria exilis, Digitaria iburua) in Togo.
      • Portères R.
      Les céréales mineures du genre Digitaria en Afrique et en Europe [Minor cereal Digitaria species in Africa and Europe].
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      The positive mean scores of the items and the correlation of the construct with intention to consume fonio suggested that these qualities should be emphasized to stimulate fonio consumption in urban areas. The women also liked fonio because of its traditional value. This finding confirmed the results of Konkobo-yameogo et al,
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      who reported that in urban areas in Mali and Burkina Faso, fonio is also considered as an African food and consumers like it because it is a food traditionally included in their dietary pattern.
      Health behavior identity appeared to be a good mediating variable for stimulating a positive attitude toward fonio consumption. This finding indicates that women will evaluate the consequences of fonio consumption more positively, when they agree that fonio is good for them and their household members. Previously, Sun et al also found a significantly positive correlation between health behavior identity and attitudes towards iron-fortified soy sauce consumption.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      Health behavior identity was also positively associated with perceived barriers, indicating that women perceive more barriers when they are convinced that consuming fonio is good for them. Conversely, the association between intention and behavior is lower when the perceived barriers are higher. Sun et al also demonstrated that Chinese women perceived more barriers when they agree that iron-fortified soy sauce was good for them and their household members.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      The results of this study indicated 8 significant barriers to consuming fonio, including availability in city markets, restaurants, or canteens; lack of consistent supply throughout the year; high cost of fonio products; hard texture coupled with time-consuming cooking process; a lack of knowledge related to preparing and cooking; poor quality of fonio (dirty and filled with sand) cooked at home; large family size requiring a larger amount of fonio; and an apathetic head of household. The present results not only support the barriers reported by Konkobo-yameogo et al,
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      but they revealed that other factors are also likely to limit fonio consumption in Bamako. One of them was the lack of knowledge about processing and cooking. Indeed, because of the very small size of fonio grains, threshing, removing husks and hulls, and milling are time consuming; it takes nearly 1 hour to peel just 1 to 2 kilos of fonio by hand.
      • Cruz J.F.
      Fonio: a small grain with potential.
      After a complete dehulling, the grain is still contaminated with sand and dust, and needs to be carefully washed several times using a traditional sedimentation method to get a cleaned product. The resulting product must be steam cooked at least 3 times to get a soft-in-mouth and easy-to-digest product.
      • Cruz J.F.
      Fonio: a small grain with potential.
      This cleaning and cooking process requires some basic ability and knowledge that might not be common among all women, especially in urban areas.
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      Another reported bottleneck was the size of the household. This factor could be related either to the high cost of fonio products compared to rice, which would make it difficult to afford large amounts to feed the entire household, or to the difficult cleaning and cooking process, which might increase cooking time in large-sized households. The apathy of the head of the household for fonio consumption might be related to the low quality of the fonio-based food items served by the women in the households owing to their lack of knowledge about cleaning and cooking. Reducing these barriers might help increase fonio consumption in the households in Bamako.
      Concerning the factors of background and perception, knowledge and susceptibility factors showed the strongest correlations with health behavior identity, but the value to health was the best predictor. Sun et al also showed that health value was highly correlated with health behavior identity in rural areas, and in urban areas, knowledge, susceptibility and severity were significantly correlated with health behavior identity.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      The items of health value included importance of health in life; survival, growth, intelligence, and school performance of the children; importance of income for survival; importance of weight maintenance; and their own survival. So, whether women think that fonio is good for them was mainly determined by general value perceptions of health rather than specific health issues, such as iron deficiency or diabetes. Almost all of the previous studies used the behavioral models to understand the consumption behavior of specific nutrient-rich food such as iron-fortified food,
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      soy products,
      • Rah J.H.
      • Hasler C.M.
      • Painter J.E.
      • Chapman-Novakofski K.M.
      Applying the Theory of Planned Behavior to women's behavioral attitudes on and consumption of soy products.
      dairy products,
      • Kim K.
      • Reicks M.
      • Sjoberg S.
      Applying the Theory of Planned Behavior to predict dairy product consumption by older adults.
      legumes, and vegetables.
      • Blanchard C.M.
      • Fisher J.
      • Sparling P.B.
      • et al.
      Understanding adherence to 5 servings of fruits and vegetables per day: a Theory of Planned Behavior perspective.
      This study was concerned with an indigenous cereal, consumption of which has been often associated with cultural and religious beliefs, hence the link with a particular micronutrient was not as evident. And although previous studies on fonio reported the potential of fonio in the treatment of diabetes, stomach diseases, and blood loss after women give birth,
      • Adoukonou-Sagbadja H.
      • Dansi A.
      • Vodouhe R.
      • Akpagana K.
      Indigenous knowledge and traditional conservation of fonio millet (Digitaria exilis, Digitaria iburua) in Togo.
      no scientific evidence of the relationship between fonio consumption and the treatment of the aforementioned diseases has been demonstrated so far. Therefore, an intervention aiming at increasing the intention to consume fonio needs to positively influence the background and perception of the women, with an emphasis on the general value of health associated with fonio consumption.
      Concerning the external factors, the subjective norms were correlated with the behavioral intention, but they were not good predictors. The present results confirmed the findings of Rah et al,
      • Rah J.H.
      • Hasler C.M.
      • Painter J.E.
      • Chapman-Novakofski K.M.
      Applying the Theory of Planned Behavior to women's behavioral attitudes on and consumption of soy products.
      who also showed that the subjective norms were correlated with the behavioral intention but predicted it more weakly than the attitudes. Opinions of family, neighbors, and the husband were the most important items included in this factor in this study. In the context of Africa, values of extended family and community also significantly influence the behavior of the individual.
      • Airhihenbuwa C.
      • DeWitt W.J.
      Culture and African contexts of HIV/AIDS prevention care and support.
      • Stephenson R.
      • Baschieri A.
      • Clements S.
      • Hennink M.
      • Madise N.
      Contextual influences on the use of health facilities for childbirth in Africa.
      In Mali, the husband has a crucial role in decision making within the household. For example, in the Demography and Health Survey,
      • Diarra M.
      • Sy K.
      • Cissé S.
      Nutrition et état nutritionnel [Nutrition and nutritional status].
      women reported that husbands alone make the decisions regarding daily household purchases (63%), and which food to cook each day (33%). In the authors' sample, 67% of the women were married, and most of them agree that the opinion of their husband is very important for them. Thus, nutrition education regarding fonio should first address positive attitudes, but also influencing the beliefs of men, family, and the neighborhood about fonio consumption would be an important step for the promotion of fonio to be more efficacious.
      Cues to action (from external factors), composed of items such as food shortage, media, important ceremonies, special events, presence of guests for dinner, and invitation to restaurants, were not significantly associated with intention to consume fonio. The present results did not confirm those of Sun et al, who found a positive association between cues to action and behavioral intention.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      Given that the median score of the items was positive and that previous literature reported fonio as a shortage food item,
      • Vietmeyer N.
      • Borlaugh N.
      • Axtell J.
      • Burton G.
      • Harlan J.
      • Rachie K.
      Fonio (Acha).
      • Portères R.
      Les céréales mineures du genre Digitaria en Afrique et en Europe [Minor cereal Digitaria species in Africa and Europe].
      a special event food item,
      • Sidibe A.
      Le fonio au Mali [Fonio in Mali].
      • Adoukonou-Sagbadja H.
      • Dansi A.
      • Vodouhe R.
      • Akpagana K.
      Indigenous knowledge and traditional conservation of fonio millet (Digitaria exilis, Digitaria iburua) in Togo.
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      and a food item usually consumed in the restaurants,
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      it was a bit surprising that this relationship was not significant in the current study.
      The high reliability of the multiple constructs (0.77 to 0.95) and the positive correlation within most of the constructs suggested the adequacy of the model for the purpose of this study. However, some limitations need to be considered for future research. First, the authors found that almost 40% of the women consumed fonio once a week or more. This frequency is much higher than the 10% for several times/wk previously reported for urban areas in Guinea (Conakry) and Burkina Faso (Ouagadougou).
      • Konkobo-Yameogo C.
      • Chaloub A.O.
      • Kergna N.
      • Bricas Y.
      • Karimou R.
      • Ndiaye J.L.
      La consommation urbaine d'une céréale traditionnelle en Afrique de l'Ouest: le fonio [Urban consumption of a traditional cereal in West Africa: Fonio].
      Hebert et al concluded that self-report of dietary intake could be biased by social desirability or social approval, especially when correct or desirable answers are easily recognizable.
      • Hebert J.
      • Clemow L.
      • Pbert L.
      • Ockene I.
      • Ockene J.
      Social desirability bias in dietary self-report may compromise the validity of dietary intake measures.
      So, awareness of the study purpose could have created social desirability bias in the answers of the women, and they could have overestimated their fonio consumption. Second, almost all women tended to agree with the statements, as shown by the high values of the median scores. Hofstede and Hofstede,
      • Hofstede G.
      • Hofstede G.
      Allemaal andersdenkenden - omgaan met cultuurverschillen [Cultural Differences].
      interested in the “individualism vs collectivism” dimension of cultural behavior, showed that West African countries can be characterized as more collectivistic, where direct confrontations are considered as rude and undesirable and the word “no” is seldom used, as it is considered confrontational. Consequently, for the Likert scale, this cultural behavior could indicate that people from West African countries have a tendency to agree (positive score). In Mali, no research has been done on response patterns to Likert items. In the present study, the influence of cultural behavior on the answers was minimized by carefully training the respondents to understand the Likert scale, and by using a 5-point Likert scale to allow for variation, even if the answers are only positive. Third, Ajzen and Fishbein recommended that researchers should always conduct a pilot study, in which open-ended questions are used to obtain significant beliefs from a sample similar to the one that will be used in the main study.
      • Ajzen I.
      • Fishbein M.
      Understanding Attitudes and Predicting Social Behavior.
      Although this recommendation has been followed up in the present study through the food APS study, a large part of the variance in the behavioral intention could not be explained, suggesting that some factors could have been left unexplored.
      Overall, this study revealed that the women living in urban areas in Mali had positive attitudes toward fonio consumption and a positive evaluation of the consequences of fonio consumption on their health. However, barriers such as a time-consuming cooking process and lack of knowledge related to preparing and cooking fonio should be reduced to ensure that intention leads to effective fonio consumption.

      Implications for Research and Practice

      Baranowski et al emphasized the importance of using theory to develop nutrition-based interventions.
      • Baranowski T.
      • Cullen K.
      • Baranowski J.
      Psychosocial correlates of dietary intake: advancing dietary intervention.
      The results of the present study suggested the potential role of a nutrition education program for promoting the consumption of fonio in urban areas in Mali. An increase in fonio consumption may strengthen livelihoods of fonio producers, processors, and retailers, and contribute to dietary energy supply for households, especially during the food shortage season. The model of Sun et al was useful for identifying factors that could be important in promoting fonio consumption among women of reproductive age in Bamako.
      • Sun X.
      • Guo Y.
      • Wang S.
      • Sun J.
      Predicting iron-fortified soy sauce consumption intention: application of the Theory of Planned Behavior and Health Belief Model.
      This goal could be achieved through stimulating positive attitudes; influencing the opinions of men, family, and neighbors; and improving the processing and the skills of women who prepare fonio. Future research should be designed to investigate whether promoting fonio in urban areas would help improve economic benefits and household food security, and further studies using behavioral models should pay attention to identifying more specific beliefs.

      Acknowledgments

      This research was funded by the FP6 European Union INCO-FONIO project No. 0015043. We acknowledge late Guindo Doré (Institute or Rural Economics, Mali) for giving the opportunity to conduct the field work; Jean-François Cruz (Center of Agricultural Research; general manager of Fonio project) for institutional support; Jan Burema (Wageningen University) and Olga Souverein (Wageningen University) for statistical advice; and all the women for their willingness to participate and their important contribution to the study.

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