Gender- and culture-sensitive nutrition programming

[Individual articles from the Winter 2017 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]

Nutrition programs often target groups most visibly linked to desired nutrition outcomes. For example, since nutrition is key to children’s development during their ‘1000 golden days’, mothers with young children or women of childbearing age tend to be targeted to promote good nutrition for infants. As other articles in this issue contend, though, a narrow participant focus may limit the impact of nutrition programs and ignore the role that other family members play. At the same time, looking only at broad, household-level indicators of nutrition may miss different household members’ unique vulnerabilities. Nutrition programs are more effective and relevant when they are sensitive to family power dynamics, local practices and culture. This article offers ideas for integrating gender and cultural context into planning, monitoring and evaluating nutrition programs. While these ideas are not exhaustive, they offer a starting point for thinking through gender and cultural issues that affect nutrition.

Look within the household

Sufficient, nutritious food available at the household level does not ensure that all members will have access to enough food to meet their dietary needs. Intra-household distribution of food, family decision-making systems and cultural practices and taboos mean that the nutritional status of family members within one household may be widely different. As Gurung and Ghimire observe in their article, women in some households in Nepal eat after other family members have had their fill, which can limit their access to preferred foods like meat or vegetables. Looking simply at whether the household unit has enough food would miss this kind of variation in access to nutritious food within the household.

Collecting gender- and age-disaggregated data on diets for each member of the household using tools such as the Household Dietary Diversity Score provides insight into the unique nutrition status of different family members. Alternatively, Lee and Hembroom in their article describe a project in Nepal that has started to collect data on the number of times women in participant households skip meals. Since women eat last in this cultural context, the number of meals skipped by this population will be a more sensitive indicator than the number of times the entire household skips meals.

Disaggregated data may also reveal needs among populations who are not always targeted in nutrition interventions. While pregnant and lactating women and young children are generally known to be vulnerable to malnutrition, other household members, like elderly members or adolescent girls, might also be receiving insufficient food or nutrients for their needs. For example, after the April 2015 earthquake in Nepal, MCC worked with partner organization Shanti Nepal to distribute rations of ready-to-eat food that included nutritious and locally-sourced chiura (beaten rice flakes) and roasted lentils. However, while distributing these rations to highly-affected rural households in Dhading district, Shanti Nepal staff realized that young children and elderly people may lack the teeth necessary to eat such hard and crunchy food. They adapted the ration to include easier to eat instant noodles. For subsequent disaster responses, MCC and partners in Nepal have included a nutritious porridge flour mix in the emergency rations intended for young children and elderly people.

Identify decision-makers and agents of change

When planning projects, analyzing family systems and power dynamics within a household can help identify gatekeepers and potential agents of change. Nutrition programs often focus on health and agriculture activities, but addressing household power dynamics within family relationships and organizing anti-domestic violence activities can also lead to better nutrition outcomes. In Nepal, newly married women traditionally move into their husband’s family home and often take on a large portion of household duties. Mothers-in-law make decisions about their daughters-in-law’s work and also often have strong ideas about food taboos in pregnancy or for young children.

An MCC-supported project run through partner organization Sansthagat Bikas Sanjal and implemented by Interdependent Society in Surkhet district facilitates discussions between mothers-in-law and daughters-in-law and between husbands and wives. These discussions encourage shared understandings about good nutrition practices and provide opportunities to discuss family relationships. By encouraging shared knowledge about nutrition and by improving communication, the family members who make household decisions about money, household duties and food can work together toward improving nutrition for all family members. This project has reported that after these discussions mothers-in-law and husbands have started providing support to pregnant and lactating women by recognizing their specific nutrition needs, encouraging health check-ups and reducing their household workload. As noted in the article by Gurung and Ghimire, other projects in Nepal have also successfully engaged male family members to encourage better household nutrition practices.

Some family members may be better able to promote changed household practices than others. As Rahaman and Rahman point out in their article, identifying agents of change within a household, like students in Bangladesh, smoothes the process of change. In this case, project implementers found that parents who were reluctant to try new agricultural techniques themselves were willing to support and learn from their children, which led to diversified livelihoods and diets for participant households. Similarly, Climenhage notes that in Labrador, Canada, the Community Food Hub’s children’s garden is one of its most successful programs, working through students to promote healthy eating at home. Meanwhile Sarker and Rahman examine in their article how women’s heavy investment in the long-term good of the household led the monga mitigation project to select women as primary participants in asset transfers and project trainings.

Decide what to accept

Identifying cultural practices that affect nutrition also requires analysis of when to encourage different practices and when to simply offer alternatives that achieve the same nutrition outcomes. It may be a slow process to change the cultural perception in Nepal that pregnant women should not eat Vitamin A-rich papaya because of fears that it will cause miscarriage. Ultimately it may be more effective to promote carrots or eggs as alternate sources of Vitamin A that do not come with cultural taboos attached. Perhaps a comparable example is the idea that North Americans could consume less red meat if they started eating insects as a healthier and more sustainable protein option. In many cultures, insects are commonly eaten as snack foods. However, because of many North Americans’ revulsion at the thought of eating insects, a nutrition project that promotes beans and legumes as a substitute for red meat is likely to be more successful. Similarly, Wade and Yameogo observe in their article that the success of integrating moringa into diets in rural Burkina Faso links with the traditional practice of consuming moringa as a healthful medicinal plant and with the project’s demonstrations of how it can be adapted into traditional foods.

Gender- and culture-sensitive nutrition programing requires intensive analysis of family systems, intra-household power dynamics and awareness of taboos and cultural practices related to food consumption. Food insecurity affects communities, households and family members in diverse ways, requiring project approaches that recognize and build on the local context in order to address malnutrition successfully. Deep knowledge of the local community’s culture, traditions, eating habits and practices is essential and requires careful attention at all stages of a project. Such knowledge is often most accessible to those with close community ties. A community-driven approach that builds on the existing knowledge of local organizations and their relationships with community members can help navigate societal and cultural complexities and ultimately lead to better nutrition outcomes for all people in a community.

Martha Kimmel is MCC Nepal food security advisor. Leah Reesor-Keller is MCC Nepal co-representative.

Learn more

Madjdian, Dónya S. and Hilde A.J. Bras. “Family, Gender, and Women’s Nutritional Status: A Comparison between Two Himalayan Communities in Nepal.” Economic History of Developing Regions 31/1 (2016): 198-223.

Mother’s education as a predictor of child malnutrition in Nepal

[Individual articles from the Winter 2017 issue of Intersections will be posted on this blog each week. The full issue can be found on MCC’s website.]

Many people assume that household food insecurity is the main driving force behind childhood malnutrition and stunting. Simply put, the common assumption is that children are underweight because their families lack access to sufficient amounts of healthy food. However, a research study conducted by the Brethren in Community Welfare Society (BICWS) in the southern plains region of Nepal on the socioeconomic and cultural barriers to good nutrition found a more complicated picture. The study’s findings imply that while improving household food security may be necessary, it alone is insufficient to improve the nutritional status of children. The results suggest that malnutrition and stunting in this context are the result of interconnecting socioeconomic, educational and health-care factors. This study, alongside other research, suggests that an integrated strategy that improves the overall socioeconomic well-being of families, maternal education and knowledge of infant and young child feeding practices will be more effective and sustainable in improving the nutrition of children living in poverty.

BICWS operates as the service arm of the Brethren in Christ church conference in Nepal, based in the southeastern city of Biratnagar. Since many families in BICWS’ working area are rural landless households facing malnutrition, BICWS and MCC worked together to develop a food security project funded by MCC’s account at the Foods Resource Bank that included supplementary food for malnourished children as one of the project components, coupled with kitchen gardening and support for commercial vegetable and fish production.

Despite the short-term effectiveness of the supplementary food seen in many of the project participants, some malnourished children showed inadequate growth over the year of nutrition support, necessitating their re-enrollment for another year. BICWS conducted a research project in 2015 aimed at discovering the socioeconomic and cultural barriers and risk factors to healthy childhood development and recovery. The study involved in-depth interviews with participant households whose children did not recover from malnutrition and with participant households whose children recovered quickly.

The results of the study suggest that the initial hypothesis of food insecurity as the main driving force behind childhood malnutrition holds true, though only for the most extreme cases of households experiencing poverty and debt. It stands to reason that significant debt and related financial insecurity are major risk factors for childhood malnutrition. Families burdened by large debt payments have little or no financial security during periods of stressors, such as strikes, illnesses or disasters. In 2015 Nepal underwent a number of concurrent stressors, including a devastating earthquake, nationwide political unrest, strikes and an economic blockade from India. Health was one of the first things to deteriorate. Instead of a significant drop in caloric intake, affected families chose instead to drop many types of nutritious foods while keeping the amount of food consumed the same. Lack of dietary diversity contributes to malnutrition. While 80% of interviewed families stated that they normally had enough money for food, only 36% of families consumed the minimum daily nutrition requirements, showing a large gap between perceived food sufficiency and actual nutrient sufficiency.

For the non-extreme cases of malnutrition, however, the study discovered that the low level of mother’s educational attainment was connected with the incidence of malnutrition in children. That is, in families where the mother was more educated, children exhibited fast recovery. Other research projects in Nepal support this finding. This result suggests that women’s low educational attainment is linked to community malnutrition and that encouraging education is a strong potential long-term solution.

Nutrition-specific knowledge is also important. The study found that even some educated women lacked knowledge about health care, nutrition and sanitation. Lack of knowledge limited their application of good nutrition practice. However, BICWS found that educated women were more likely to take ownership of supplemental food received and to practice new nutrition skills than women with lower educational levels, despite the fact that both educated and uneducated women demonstrated low levels of nutritional knowledge before the project started. It makes sense that women’s education is likely to have an impact on family nutritional status, given the fact that in this community women normally serve as the center of the nuclear family and generally decide on and prepare daily meals. In response to these findings, BICWS has implemented a new strategy aimed at reaching three thousand households with nutritional education, equipping families (in particular women) with the knowledge of what nutritional strategies contribute to healthy development and overall well-being.

The BICWS research suggests that women’s education can be a cushion against stressors that lead to poverty and malnutrition. Women’s education and empowerment must be emphasized, especially as women in rural Nepal are often marginalized, with limited access to education and authority. Any long-term plan for community improvement should consider increasing women’s access to education as a key strategy. At the very minimum, this study suggests that nutritional education should be emphasized in any population suffering from malnutrition.

Derek Lee was on a SALT assignment with BICWS in 2015-16. Shemlal Hembrom is the program director of BICWS and General Secretary of BIC Nepal.

Learn more

Dhungana, Govinda Prasad. “Nutritional Status of Under 5 Children and Associated Factors of Kunchha Village Development Committee.” Journal of Chitwan Medical College 3/4 (January 2014): 38–42.

Osei, Akoto, Pooja Pandey, David Spiro, Jennifer Nielson, Ram Shrestha, Zaman Talukder, Victoria Quinn and Nancy Haselow “Household Food Insecurity and Nutritional Status of Children Aged 6 to 23 Months in Kailali District of Nepal.” Food and Nutrition Bulletin 31/4 (December 2010): 483–94.

Singh, G.C. Pramood, Manju Nair, Ruth B. Gruibesic and Frederick Connell. “Factors Associated with Underweight and Stunting among Children in Rural Terai of Eastern Nepal.” Asia-Pacific Journal of Public Health/Asia-Pacific Academic Consortium for Public Health 21/2 (April 2009): 144–52.

Understanding stories of trauma

In many cultures, including Congolese culture, storytelling functions as a means of preserving and transmitting historical memory while building community solidarity. Narrative also plays a therapeutic role in reducing the psychosocial impact of trauma by allowing individuals or groups to tell their stories and listen to the stories of others within safe spaces (Kiser, 51). However, in some cases traumatic events are so horrific that survivors choose to suffer in silence. Fear of retribution and rejection prevent those who have experienced the trauma of rape from acknowledging the event and seeking assistance. My research with Congolese women who have been raped has underscored the key role that narrative can play in assisting rape survivors and others in understanding the trauma of rape and in helping rape survivors heal from that trauma.

Sexual- and gender-based violence (SGBV) is rampant in the Democratic Republic of Congo (DRC). A 2009 study found that 462,293 Congolese women, aged 15 to 49 years, reported having been raped within the past year (Peterman, Palermo and Bredenkamp, 2011). This stunning figure excluded girls under the age of 15 and women over the age of 49 who had also experienced this horror. Furthermore, for a number of reasons, many women choose not to report their attacks. Reporting rape too rarely ends in any form of justice for the victim and can often have negative effects, with raped women facing stigma, discrimination and retribution.

In February 2014, I collected stories from 14 women who had survived rape in the eastern DRC as part of dissertation research into trauma healing for SGBV survivors. I assessed interview data using narrative analysis techniques to identify themes that surfaced across all of the interviews, using that data to then compile one biographic narrative using the data and themes from all of the narratives. While I had planned for only ten interviews, many more women requested the opportunity to share their stories of rape and its aftermath. Nearly all of the women I interviewed expressed gratitude for the opportunity to share their stories and asked that I share their stories so that other women might find healing.

One of the primary goals of the narrative approach to trauma healing is to increase awareness of the dominant stories that shape the lives of storytellers (Bennet, 12-13). Becoming aware of these dominant narratives can assist rape survivors in identifying and developing responses that can bring healing and build resilience for individuals and communities. The narrative approach I employed in my research consisted of very loosely structured interviews. In responding to a limited set of interview questions, my informants focused on the key aspects of their own stories of rape as they experienced and remembered it. Rather than adopting a structured interview style focused on eliciting information about particular topics, I sought through more free-flowing interviews to allow my informants to identify the crucial dimensions of their experiences and memories.

The findings of my study resonated with a theory of social justice developed by Madison Powers and Ruth Faden, whose work in philosophy and bioethics has articulated how indicators of human well-being can serve as a measure of social justice. Powers and Faden have described six essential dimensions of human well-being: health (physical and mental); respect (self-respect and respect from one’s family and community); reasoning (ability to engage in coherent, rational thought); attachment (presence of intimate relationships); self-determination (ability to exercise agency); and personal security. While Faden and Powers grant that one can have a decent life without having a high threshold in all six of these dimensions, they do contend that human well-being can be negatively affected by a serious deficiency in one or more of these dimensions.

My research with Congolese rape survivors found that the traumatic experiences these women had undergone significantly affected their wellbeing in all six dimensions of human well-being identified by Powers and Faden. That said, the dimensions of well-being most adversely affected, I discovered, were attachment and respect. Though many of the women had suffered significant physical trauma, most only mentioned their physical injuries after I questioned them specifically about physical complications resulting from the attack. The majority of my interviewees, however, did highlight in their narratives the pain of rejection by their husbands and/or stigma they faced from other community members because they had been raped.

Stigma toward rape victims, particularly stigma from other women, often results from a need on the part of stigmatizers to distinguish themselves from persons who have been raped. This distinction acts as a pseudoprotective measure, cultivating the illusion that one is definitively safe from suffering the same fate as the victim (Grubb and Turner, 2012).

Trauma healing, awareness and resilience efforts aimed at addressing the particular needs of rape survivors must therefore pay particular attention to deficits in attachment and respect. My research found that narrative opportunities for rape survivors to share their stories can contribute to a reduction in the stigmatization and discrimination of rape survivors in at least two ways. First, by affirming and supporting rape survivors in exercising self-determination as they share their stories, thus building their resilience as individuals and in turn strengthening their confidence in fostering intimate attachments and building relationships. And second, by expanding and deepening family and community understandings of rape and the experiences of women who have faced it, in turn reducing the stigmatization of rape survivors. Storytelling by rape survivors thus becomes a key way of expressing and building individual and communal resilience.

Beth Good is MCC’s Health Coordinator and holds a Ph.D. in Nursing.

Mennonite women as conscientious objectors

Shortly after the Second World War began in 1939, women in Ontario organized their local sewing circles into the Nonresistant Relief Sewing Organization. In describing the humanitarian assistance and moral support given to conscientious objectors in camps and war sufferers overseas, secretary Clara Snider said: “We are representing a common cause and stand for the same principles. . . . United we stand, divided we fall.”

American Edna Ramseyer, writing in 1943, reflected a similar desire that women be included in the discourse on nonresistance and conscientious objection. She asked: “Have you ever wished that you could prove your convictions on peace and war as your boyfriend, husband, brother, or son has? . . . Girls and women of the Mennonite church groups! Our Christian responsibility, to our God, the world, the church, our boys . . . is tremendous. The challenge is before us; the projects await us; the question is, do we as girls and women want to serve?”

These Mennonite women were not called up to serve their country militarily, but they nevertheless chose to identify as conscientious objectors and to provide an ‘alternate service’ to their country and to humanity. Indeed, they served voluntarily while Mennonite men were required to provide service to the state in eras when military conscription was enacted. And while men were confronted with the question of what they ‘would not do’ during war, women considered what they ‘would do’ in the midst of conflict. What they did was offer a ‘positive peace’ in the form of material and moral relief and service to those who suffered from the violence of war.

Mennonite women, and others from historic peace churches, expressed their conscientious objection in both world wars of the twentieth century by providing material relief and voluntary labour, both to their own men in work camps for conscientious objectors (COs) at home and to war sufferers overseas. During the Second World War, a church-administered work program for COs in the United States called Civilian Public Service (CPS) drew women into labour as nutritionists, nurses, cooks and other roles within the 151 CPS camps established across the country.

In Canada, the Alternative Service (AS) work program for COs was government-run, and so women were not as involved in the camps. Yet Canadian women declared a pacifist stance by sending care packages and letters to their own sons and husbands in AS camps and by entering paid employment in order to support their families in the absence of male wages.

Mennonite women’s organizations across Canada and the United States prepared clothing, bandages, food and other relief goods to be sent directly overseas and held sales and other events to raise money to support organizations engaged in wartime relief. Relief workers in England suggested that women in Canada and the United States adopt the slogan “Non-Resistant Needles Knitting for the Needy” to underscore the “magnificent opportunity” that their work represented. A 1940 report on Mennonite Central Committee’s relief clothing program for war sufferers in Europe described the relationship between relief and peace thus: “In the face of war’s havoc there is need for a positive testimony of peace, love, and compassion toward the suffering.”

The voluntary ‘positive peacemaking’ of women was literally embodied as numerous young women went overseas themselves, during and after the war, to work in orphanages and refugee centres and to distribute food and clothing. Arlene Sitler of Ontario was one woman who took up this opportunity: she affirmed the material relief provided by Mennonite women, suggesting that through their giving “the bonds of peace and Christian fellowship may become stronger throughout the world.”

Women continued to demonstrate a ‘positive peace’ in the decades after the Second World War, volunteering for overseas relief work or domestic voluntary service in high numbers. Between 1940 and 1970, for example, nearly twice as many Canadian women did service with MCC as Canadian men (Epp-Tiessen, 63). Moreover, during the Vietnam War draft in the U.S., when most of the 89 men in MCC service in Vietnam were there to perform the required alternative service duty, 39 women were there completely voluntarily. Women have also demonstrated a keen commitment to active nonviolence through their participation in Christian Peacemaker Teams.

If notions of Mennonite nonresistance, as expressed by male church leaders, shifted from a passive to an active pacifism in the latter part of the twentieth century, it could be argued that such a shift had already been anticipated in the words and actions of Mennonite women.

Marlene Epp is professor of History and Peace & Conflict Studies at Conrad Grebel University College, Waterloo, Ontario.

Learn more by reading the Winter 2015 issue of Intersections – Conscientious objection.