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.

Addressing cultural barriers to nutrition 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.]

In the Nepali context, household access to sufficient food does not ensure that all household members are well-nourished. Cultural beliefs about food consumption can lead to low nutritional status, particularly for highly-sensitive groups such as pregnant and lactating women and young children. Deep-rooted beliefs about food can present barriers that inhibit adoption of new, more nutritious food consumption practices. These barriers are in turn compounded by low levels of formal education in rural areas of Nepal and by strong hierarchies in families in which older, more traditionally-minded family members make decisions about food consumption in the household. This article explores the importance of engaging multiple stakeholders within the household in order to change cultural perspectives on nutrition.

One example of a common cultural practice that affects nutrition in Nepal is the categorization of foods into ‘hot’ or ‘cold’. These categorizations, unrelated to the physical temperature of food, reflect perceptions of how foods will affect the body after consumption. During critical periods such as pregnancy, lactation and illness, it is common practice to avoid eating foods classified as ‘cold’ in order to protect the body in its vulnerable state. For example, pregnant women may be warned to avoid eating certain vitamin-rich fruits and vegetables like papaya or spinach because these foods are considered cold.

Other cultural practices that affect nutrition may affect various household members differently. Baby boys are commonly exclusively breastfed until six months of age, while baby girls are generally offered their first solid food earlier, at five months of age. In some cultural groups, women family members eat meals last, after everyone else in the family has had their fill. Ultimately, these practices can contribute to poorer health status, including anemia and malnutrition for children under three and for women during pregnancy and lactation.

Lack of nutrition knowledge is the main reason for the persistence of traditions that negatively influence nutrition status in the community. In order to address this situation, the Rural Institution for Community Development (RICOD) has been disseminating appropriate nutrition knowledge and skills in rural communities of the southern Lalitpur district. In these trainings RICOD raised awareness about effective nutrition practices aimed not only at mothers of young children and pregnant women but also at those who traditionally hold decision-making power in their households, namely, the women’s in-laws and husbands. In order to ensure that such trainings, which aimed to change traditional practice, were also  culturally sensitive, RICOD’s staff focused on providing general nutritional advice, such as counseling pregnant women to consume diets rich in vitamins, rather than targeting and criticizing specific cultural practices, like avoiding green leafy vegetables (a ‘cold’ yet vitamin-rich food) during pregnancy.

Trainings generally targeted women with young children by teaching an in-depth nutrition curriculum in mothers’ groups and then reviewing and doing refresher trainings on that curriculum. Mothers-in-law were also often part of these groups, so these workshops included more powerful players in household decision-making. Additionally, RICOD organized workshops for men in the targeted households, because decisions in Nepal about buying food and about agricultural plans are traditionally made by male heads-of-household, including fathers-in-law and husbands of women with young children. Therefore, men’s understanding was crucial for households to start acting on new nutrition knowledge. RICOD also promoted learning and sharing opportunities between women and men on the importance of nutrition for women and children during vital periods. These meetings aimed to lower cultural barriers to acting on good nutrition knowledge.

More recently, RICOD organized nutrition awareness trainings for school-aged adolescents (men and women) to provide knowledge to younger generations. Not only are the nutrition facts important for these adolescents to know as future parents, these young men and women also tend to be well-placed to disseminate the information to their parents and neighbors.

In addition to teaching new information, RICOD recognized the importance of peer education in changing traditional practice. To promote learning and sharing opportunities among women, RICOD worked with existing mothers’ groups linked to local health posts to strengthen their functioning. Through these meetings, participants exchanged ideas and shared knowledge about nutrition and health. Participants then also shared the new knowledge they gained from the groups with their neighbors and relatives. RICOD also promoted kitchen gardening and empowered women by providing access to capital via revolving loans administered by these women’s groups. Kitchen gardens increased women’s access to homegrown vegetables while revolving loans stimulated small enterprises that in turn generated additional income for households to buy nutritious food.

Besides promoting peer education through women’s groups, RICOD provided in-depth training to volunteer peer educators on good nutrition practices. Peer educators are youth residing in the local community who regularly visit targeted households to encourage them to practice good eating habits. Additionally, some peer educators attend the monthly mothers’ group meetings, where they lead discussions on nutrition-related topics.

RICOD’s work has led to important learnings for future nutrition programs. In particular, understanding traditional beliefs and eating habits is essential for knowing how to promote improved nutrition practices. Broad dissemination of nutrition information should take place in order to teach many people within a community. RICOD also found that working with more than just one household member was a key to healthy changes in traditional practices. By training both men and women and both younger and older generations on the importance of nutrition and good nutrition practice, RICOD was more effective in creating change within households. Not all of this change came easily. Changing older generations’ traditional beliefs was a challenge, since it takes a long time to change traditional practice and behavior. Even now, not everyone has changed their traditional practices. RICOD’s work and encouraging results demonstrate, though, that exposure to better eating habits and continuous follow-up can lead to changed knowledge, skills and practice.

Additionally, peer education and coordination by non-governmental organizations like RICOD with other health providers, like Nepal’s Female Community Health Volunteers, are important so that people regularly hear the same message about good nutrition practice from multiple sources. Mobilization of local community members to disseminate nutrition knowledge can help lower cultural barriers through peer education and regular follow up. That regularity is key to changing long-held practices. Changing tradition is a slow process, but new knowledge and understanding can over time lead to positive changes in nutritional practice and health.

Honey Gurung is field coordinator and Ram Hari Ghimire is executive director for the Rural Institution for Community Development (RICOD).

Learn more

Adhikari, Ramesh Kant. Food Utilization Practices, Beliefs and Taboos in Nepal: An Overview. United States Agency for International Development, Global Health Technical Assistance Project (May 2010). Available at pdf.usaid.gov/pdf_docs/pnaeb772.pdf.

Alonso, Elena Briones. The Impact of Culture, Religion and Traditional Knowledge on Food and Nutrition Security in Developing Countries. FOODSECURE Working Paper No. 30 (March 2015). Available at www3.lei.wur.nl/FoodSecurePublications/30_briones.pdf.

Khatry, Subarna K., Steven C. LeClerq and Sharada Ram Shrestha. “Eating Down in Pregnancy: Exploring Food-Related Beliefs and Practices of Pregnancy in Rural Nepal.” Ecology of Food and Nutrition 45 (2006): 253-278. Available at www.k4health.org/sites/default/files/Eating%20down%20Nepal%20article_Caroline%20sent.pdf.

Community-Based Network Organizations and disaster management

For many communities around the world, a major disaster presents a considerable setback in the healthy development of local infrastructure, sustainable livelihoods and economic growth for years to come. For these populations, disaster management is not a standalone issue, but one that must be incorporated into the broader activities of the community as a means of promoting ongoing recovery and prevention. Unfortunately, for small rural communities, the resources needed to undertake this type of management typically exceed what the community is able to muster itself. In Nepal, however, an effective response to this problem has been the formation of community-based networking organizations (CBNOs), which work with local communities to create a regional network that collectively takes ownership over a range of development initiatives. The linkages formed by such a network enable communities to leverage their human, economic and political capital against that of the wider network. These linkages in turn not only play a major role in disaster recovery, but also offer an effective response in mitigating against ongoing risks.

CBNOs are established and operated with the democratic principle of people-led development, putting local individuals and communities as the primary stakeholders at the forefront of their own development through their direct involvement in the planning and implementation of related initiatives. This approach, which brings together communities with similar needs and diverse capabilities, has demonstrated positive results for improving livelihoods, realizing rights and responding effectively and quickly to disasters. When, on the contrary, plans are imposed on a community by an outside actor, there is a high risk that the recipients will not take ownership of them, diminishing the prospects of successful implementation and sustainable results.

Sansthagat Bikas Sanjal, a networking organization operating throughout Nepal, focuses on uniting highly marginalised and disadvantaged people who have little access to resources. These marginalised individuals—members of lower castes and classes, Muslims, women and minorities—have lower indicators in health, education, literacy and awareness and lack access to state resources and facilities. Although these groups technically have rights formalized by the government, the lack of accountability within and instability of the political system in Nepal has failed to create functioning mechanisms and institutions for their realization. From the rights-based perspective, then, the role of CBNOs is critical, as it not only signals a break from the historic tradition that saw lower-caste individuals at the mercy of their rulers, but it also demonstrates that all citizens have the right to a better life.

In a CBNO, members from different community organizations elect representatives to lead the overarching networking body, an important characteristic that highlights one of the strengths of this model—that each member organization of the CBNO remains in its constituent community, thereby ensuring strong accountability to its primary stakeholders. In bringing together different communities, the CBNO is able to provide a broader scope for self-help through building social capital on a regional level and mobilizing resources on a larger scale.

By linking the household to the community to the region, the network rekindles the traditional spirit of cooperation in the wider society. The sharing of resources not only enhances the ability of any one constituent community to implement strategies that reduce vulnerability to disasters and improve the community’s overall wellbeing, but also motivates individuals to evaluate their own needs and be involved in seeking solutions.

This approach has made CBNOs key partners in disaster response, owing
to the fact that they have an established system that channels information and resources among member communities. Thus, when disaster strikes, the CBNO is able efficiently to assess the impact and quickly respond with the help of other community groups in the network. Additionally, the CBNO has connections to larger organizations and government bodies which provide a path for disaster-affected communities to receive assistance from sources outside their communities that they otherwise would not be able to access.

When a settlement of landless agricultural labourers in Banke district, located in south-west Nepal, was gutted by fire three years ago, the CBNO, Janajagaran Samajtook, mobilized a response from the wider network of communities that it represented. While the affected community focused on meeting its immediate needs, the network sought support to cover the more substantial expenses linked to shelter reconstruction. Thus, the CBNO approached district-based committees, organizations and development agencies, seeking aid for the rehabilitation of victims’ homes. Ultimately, Janajagaran Samajtook initiated a partnership with Mennonite Central Committee Nepal, on behalf of the affected community, for the provision of hazard-resistant construction materials that were not locally available. When the materials were received, 42 damaged houses were reconstructed within six months, with the local community contributing the majority of the labour.

As the previous example highlights, a CBNO’s strength in disaster response is the ability quickly to mobilize the assets of a wide network of communities that ensures a rapid assessment of and response to the immediate needs of affected members. By drawing on the local capacity of members for disaster response, CBNOs are able to gain information and resources quickly that allow for an immediate response to the physical and economic impacts of disasters. Within a short amount of time, communities are able to marshal resources and begin advocating with local governments and organizations to attend to urgent needs identified by the affected community that would otherwise go unmet.

Bal Krishna Maharjan is the Executive Chief of Sansthagat Bikas Sanjal,
a community-based networking organization in Nepal.

Learn more by reading the fall issue of Intersections – Community-based disaster managment.