GENDER EQUALITY
AND SOCIAL INCLUSION
FOR FOOD-AND NUTRITIONSECURITY IN NEPAL
RESEARCH REPORT
Prepared by Another Option LLC
September 2014
C O NT E NT S
ACRONYMSI
EXECUTIVE SUMMARY
II
CHAPTER I 1
INTRODUCTION1
1.1 Background
2
1.2 Objective of the Survey
3
CHAPTER 2 3
STUDY DESIGN AND METHODOLOGY
3
2.1 Study Design
3
2.2 Sample Design
3
2.2.1 Research Population
3
2.2.2 Gender Representation
3
2.2.3 Ethnic Representation
3
2.2.4 Age
4
2.2.5 Key Informants
4
2.2.6 Research Location
4
2.3 Sample and Sampling Strategy
5
2.4 Research Protocol and Data Collection Tools
8
2.5 Recruitment and Training
8
2.6 Data Collection and Analysis
9
CHAPTER 3 10
FINDINGS10
3.1 Values and Aspiration
10
3.2 Fears and Concerns
13
3.3 Breastfeeding
17
3.4 Complementary Feeding
20
3.5 Source of Information
24
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
C
ANNEX
27
A. ECOLOGICAL MODEL THEORY FOR BEHAVIOR CHANGE COMMUNICATION 27
B. BIBLIOGRAPHY FROM ANOTHER OPTION’S ASSESSMENT REPORT 28
C. KEY FINDINGS FROM ANOTHER OPTION’S ASSESSMENT REPORT 31
D. DISCUSSIONS GUIDES (SEVEN ENGLISH-VERSIONS) 52
ACKNO WL E D G E M E N T S
This report was prepared for The World Bank under the Contract 7170122, February –
December 2014. Authors of the report are Sumi Devkota and Dee Bennett, Another Option
LLC. Research design and field work by Right Direction Nepal and Another Option, LLC.
Graphic design of the report is by Greg Berger Design.
NOTE ABOUT TRANSLATION
The authors have followed American-English for the spelling of Nepali names and locations
and have attempted to be as consistent as possible. In writing and editing this report we found
several ways to spell the same word for foods, names, and locations. In editing the document
we chose the spelling most commonly used in English.
D
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
AC RO NYM S
AHW
ANC
ANM
BCC
CBS
CMAM
DALO
DGs
DHO
EPI
FCHV
GMP GON
HCW
HFMC
HKI
IYCF
MCHW
MNP
NAFSP
NID
PNC
SHD
SUAAHARA
UNESCO
UNICEF
USAID
VDC
VHW
WB
Auxiliary Health Worker
Antenatal Care
Auxiliary Nurse and Midwife
Behavior Change Communication
Central Bureau of Statistics
Community Management of Acute Malnutrition
District Agriculture Livelihood Officer
Discussion Guides
District Health Office
Expanded Program of Immunization
Female Community Health Volunteer
Growth and Monitoring Program
Government of Nepal
Health Care Worker
Health Facility Management Committee
Helen Keller International
Infant and Young Child Feeding
Maternal Child Health Worker
Micronutrient Powder
Nepal Agriculture and Food Security Project
National Immunization Day
Post Natal Care
Sunaula Hazar Din Program
USAID-funded Feed the Future Program
United Nations Educational, Scientific and Cultural Organization
United Nations Children’s Fund
United States Agency for International Development
Village Development Committee
Village Health Worker
World Bank
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
I
EX EC U T I VE S U M M A R Y
The World Bank (WB) continues to support the Government of Nepal’s (GON) thrust to
improve the food and nutrition security of its people. It already has several major investments
in agriculture and nutrition development programs, including Sunaula Hazar Din (SHD),
a Community Action for Nutrition Project, and the Nepal Agriculture and Food Security
Project (NAFSP). The World Bank initiated a behavior change communication and social
marketing activity that examined the role of gender in correct breastfeeding practices
(exclusive breastfeeding) and the proper and timely introduction of complementary feeding,
Infant and Young Child Feeding (IYCF).
Another Option was selected by the World Bank to design and manage this activity. For its
behavior change communication (BCC) the technical team followed an ecological model
(originally developed by Green & Kreuter in 1988; updated by Green, Richard, Potvin,
Ecological Foundations of Health Promotion, 1996) that reflects individual factors as well as
environmental variables (social, political, and cultural norms) that influence the mother and
her family (Attachment A). The technical team conducted a wide-reaching assessment of
secondary research data from Nepal as well as other countries with similar ethnic populations
and social and cultural norms. The team also looked at the government of Nepal’s long-term
strategies related to nutrition status and breastfeeding and complementary feeding practices,
with a view to mitigating malnutrition and the general poor health of infants and young
children. (Attachment B Another Option Assessment Report. Bibliography 2014)
The qualitative research aimed to: 1) verify the key findings of the assessment; 2) determine
the concerns and aspirations of target audiences – four ethnic minority women, their
husbands, and mothers-in-law living in the terai and the hills; 3) use this data to design
behavior change communication messages that address the barriers to the adoption of
exclusive breastfeeding practices; and 4) identify interventions to encourage and motivate
timely implementation of complementary feeding.
INCOMPATIBLE STATISTICS
The assessment data showed two statistics that are contradictory. World Bank Data 2011
show 40.5 percent of Nepali children under the age of five suffered from stunting and 29.1
percent were underweight. However, the Mid-term Survey by the Nepal Family Health Project
II shows that 90 percent of all women across all ethnic populations said they had breastfed
their children (NFHP II. Mid-term Survey. 2010). Clinical research shows that exclusive
breastfeeding for six months eliminates or reduces malnutrition, stunting, wasting, and
underweight.
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
KEY FINDINGS
The key fears and concerns that stand out among the study populations from the four
ethnic groups (Dalit, Janajati, Madhesi and Muslim) are: lack of employment opportunities,
minimum basic health and education services at local levels, and food security (hills).
These issues have contributed to the majority of the adult males that are able to work
migrating to India or other countries to earn an income, gain financial stability, and create a
better life that includes an education for their children. Women (wives and mothers) remain
at home, dealing with an overwhelming workload, a sense of isolation, and severe economic
conditions.
Two other main concerns (fears) expressed by both men and women about their lives are
gender and caste inequality. The gender inequality prevails in all castes except Janajati and is
manifest in different ways on a regular basis. Child marriage and multiple marriages are high
in the terai among Madhesi and Muslims respectively.
Mothers are less empowered having left school when they began menstruation or are married
young. This means the mothers and mothers-in-law have received less education and have
lower literacy levels. A UNESCO 2010 study shows that a child born to a literate mother is 50
percent more likely to survive past the age of five years.
Overwhelmingly the mothers, mothers-in-law, and fathers do not understand the critical
role and long-term positive affect exclusive breastfeeding and the correct introduction of
complementary feeding has on their child’s emotional and physical development. Nor do they
make the link between their aspirations for economic stability and a healthy family with their
adopting positive actions like exclusive breastfeeding. None of the audiences recognize the
financial implications of having malnourished children. World Bank Data (2012) shows outof-pocket expenses for health issues at 41.7 percent, and that expense is increasing annually.
These are indications of the gap between what mothers and families want (aspirations) and
what they do to achieve them (health practices).
Each ethnic population promotes and follow specific social and cultural practices related to
breastfeeding. For example, a high percentage of Janajati in Rukum do not feed colostrum to
newborns; Madhesi introduce honey and goat milk to newborns during the first few days after
birth; Madhesi and Muslims substitute other milk since they believe that mother’s milk does
not start for the first two days after birth; and Janajati follow the custom of introducing rice
with local wine at about three months of age.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
III
Each of these customs and social norms, or external factors, are deterrents to exclusive
breastfeeding and therefore have a direct result to Nepali children’s wasting, stunting,
underweight, and overall malnourishment.
Because almost all mothers say they have breastfed (NFHP II statistics report show
90 percentile) family members (husbands and mothers-in-law) are less supportive or
understanding of a mother practicing it. The workload for a mother does not diminish after
she has a child and exclusive breastfeeding which is time consuming, or preparing special
foods (complementary) for the child is seen as a waste of time.
Across the ethnic populations animal meats, green vegetables, and fruits that would be used
as homemade complementary foods are either not affordable or they are perceived to be
indigestible by a young child. Commercial complementary foods are also not easily accessible
(not in the shops or markets) even when affordable so low-nutrient foods like biscuits and
teas that are readily available in the home are substituted.
Parents across ethnic groups identify diarrhea and pneumonia as the health issues they fear
most. Hygiene and sanitation conditions are still below acceptable standards throughout
Nepal though statistics show an increase of access to water. And, similarly directly related to
the aspirations and actions for breastfeeding, the link between hygiene and sanitation and
diarrhea and family health is not being made.
How the target audiences receive their information and who are considered the most trusted,
credible sources of information are important data for designing effective behavior change
communication. Local FM radio stations (60 percent) seem to be the most effective mass
medium to reach our target audience followed by interpersonal communication among family
and friends (50 percent) and Female Community Health Volunteers (FCHV)/influentials (30
percent).
Whereas the most trusted sources for health information reportedly are doctors/FCHVs (80
percent), traditional healers (60 percent), family and community leaders (50 percent) and FM
radio station (30 percent). Though internet service is still nominal (6 percent) especially in the
hills, 71 percent of Nepalese subscribe to a mobile service.
IV
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
C H A P T E R
I
I NTR O D U CT I ON
1.1 BACKGROUND
The Government of Nepal and its development partners including the World Bank are
committed to improving food and nutrition security in Nepal in order to reduce malnutrition,
stunting, wasting and the general poor health status of infants and young children. World
Bank has made major investments in Nepal in two agriculture and nutrition programs
Sunaula Hazar Din, (SHD), a Community Action for Nutrition Project, and the Nepal
Agriculture and Food Security Project, (NAFSP). The World Bank also initiated a behavior
change communication and social marketing activity that includes the role of gender in
breastfeeding and Infant and Young Child Feeding (IYCF). The overall objective of all of these
programs is to have healthier Nepal citizens.
Another Option was selected by the World Bank to design and manage this activity. The
behavior change communication (BCC) approach followed an ecological model (originally
developed by Green & Kreuter in 1988; Green, Richard, Potvin, Ecological Foundations of
Health Promotion, 1996) that reflects individual factors as well as environmental variables
(social, political, and cultural norms) that influence the mother and her family. The technical
team conducted a wide-reaching assessment of secondary research data from Nepal as well
as other countries with similar ethnic populations and social and cultural norms. As part of
the assessment the team looked at the government of Nepal’s long-term strategies related to
nutrition status, breastfeeding and complementary feeding practices, with a view to mitigating
malnutrition and the general poor health of infants and young children (Attachment B.
Another Option’s Assessment Report. Bibliography. 2014).
Data from the IYCF strategy reveal that: 66 percent of babies are introduced to
complementary feeding at six to eight months; 79 percent are receiving minimum meal
frequency; and a low 29 percent have a diverse diet. Existing data from a wide-range of studies
show extremely high percentage (over 90 percent) of women across several ethnic groups
saying they breastfeed their babies, however only 30.6 to 47.3 percent admit to early initiation
of breastfeeding (Attachment C. Another Option’s Assessment Report for the World Bank.
Child and Maternal Nutrition Status and Ethnicity. March 2014).
It may be argued that if correct breastfeeding behaviors were that high even if not optimally
observed the prevalence of stunting, wasting, under-weight and malnutrition among Nepal
children would be lower. Instead, these nutrition deficiencies remain extremely high, especially
among lower socio-economic and ethnic groups.
A key finding is that conventional wisdom across audiences and populations ranging from
political and community leaders to other influentials to husbands/fathers, mothers-in-law,
and mothers is that “everyone knows about breastfeeding.” However, the reality is what they
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
1
do know are the fundamentals of breastfeeding, i.e., how to breastfeed. This knowledge is
then augmented with cultural and social practices that are specific to their ethnic population.
Too often these practices run counter to exclusive breastfeeding and correct complementary
feeding.
Examples of cultural and social practices that distract from exclusive breastfeeding are
evident are:
• Janajati in Rukum do not feed colostrum to newborns
• Madhesi introduce honey and goat milk to newborns during the first few days after birth
• Madhesi and Muslims substitute other milk because they believe mother’s milk does not
start for the first two days after birth
• Janajati follow the custom of introducing rice with local wine at about three months of age.
Each of these customs and social norms, the external factors, are deterrents to exclusive
breastfeeding which contribute to Nepali children’s wasting, stunting, underweight and overall
malnutrition.
1.2 OBJECTIVES OF THE RESEARCH
The objectives of the qualitative research were to 1) verify the key findings of the assessment;
2) identify the concerns and aspirations of the target audiences – ethnic minority women,
their husbands and mothers-in-law; and 3) to use this data to design behavior change
communication messages that reduce barriers preventing adoption of correct breastfeeding
practices and encourage and motivates timely implementation of complementary feeding.
The research was designed to identify the following:
• The aspirations and concerns of our audiences across ethnic, cultural, and social groups
that may be barriers to exclusive breastfeeding
• The communities of practice that influence and support mothers and their infants
• Social, cultural and political norms (external factors) that may prove to be the barriers or
deterrents to correct behaviors (exclusive breastfeeding) especially for the targeted socioeconomic groups and ethnic populations
• Constraints or opportunities to maximize IYCF practices among these same socioeconomic and ethnic audiences
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
C H A P T E R
2
STUDY DESIGN AND METHODOLOGY
2.1 STUDY DESIGN
There were two components of the research: qualitative analysis of key audiences (mothers,
fathers, mothers-in-law, and influencers in the community), and a market assessment of IYCF.
The qualitative research took a consultative and participatory approach. Identification of the
source and nature of these influences as well as real or perceived barriers involved targeting
both the primary audience – mothers of children under 24-months, husbands, and mothersin-law across majority Nepali and minority ethnic groups – and secondary audiences
comprised of friends (peers) and influentials. The qualitative research determined the
aspirations and dreams and the concerns and fears of the mothers and the linking of these to
their adopting correct health practices.
The market assessment of IYCF comprised a combination of observational research and
interviews with vendors, e.g., shopkeepers, pharmacists, distributors. The social marketing
component of this task helped verify the availability, accessibility, acceptance, and approval of
commercial and subsidized complementary feeding products among the primary audiences.
2.2 SAMPLE DESIGN
2.2.1 Research Population
The primary population for this research included mothers of children under 24-months,
fathers and mothers-in-law from four selected minority and majority ethnic populations
living in the terai and the hills. The research included secondary audiences of community
health care providers, educators and religious and community and private sector leaders.
2.2.2 Gender Representation
The research covered both male and female primary and secondary respondents. Among
females, the primary study populations of this research were pregnant women, mothers of
children under 24-months and mothers-in-law. The males in the study were fathers. The field
team from each study district also ensured gender balance among secondary respondents, i.e.,
health care providers, religious leaders, community leaders, business leaders, educators, civil
society and model farmers.
2.2.3 Ethnic Representation
The different ethnic groups of Nepal were represented in the research. The primary
respondents were mainly from four ethnic groups: Dalit, Janajati, Muslim and Madhesi
whereas the other ethnic groups were covered in the secondary set of respondents.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
3
2.2.4 Age
Mothers were classified into three groups: pregnant women, adolescent mother, and adult
mother above 24 years of age to ensure coverage of the age range among primary respondents.
In addition, older women were captured as mothers-in-laws. The husbands of the three
groups of mothers were also included. These arrangements allowed for representation of all
relevant age groups.
2.2.5 Key Informants
Key informants included health workers, health facility management committee members,
school management committee representatives, religious leaders, community leaders, the
media, civil society, private sector, mobile carriers and shop owners.
2.2.6 Research Location
The district sample frame for this research was the districts of the World Bank’s two projects:
NAFSP and SHD. NAFSP covered 19 districts of the mid- and far-west development hill
region (Dolpa, Humla, Jumla, Mugu, Kalikot, Pyuthan, Rolpa, Rukum, Jajarkot, Salyan,
Surkhet, Dailekh, Darchula, Bajhang, Bajura, Baitadi, Dadeldhura, Doti and Achham).
SHD covered 15 districts of the central and eastern hill and terai (Makwanpur, Sindhuli,
Ramechhap, Udayapur, Khotang, Okhaldhunga, Parsa, Bara, Rautahat, Sarlahi, Mahottari,
Dhanusha, Sira, Saptari and Sunsari).
Four hill districts (Bajhang, Achham, Rukum and Sindhuli) and four terai districts (Parsa,
Rautahat, Dhanusha and Sunsari) were selected for the research; five from SHD and three
from NAFSP. Selection of research districts was based on concentration of targeted ethnic
groups and geographical diversity. The research investigated Janjati ethnic group from
Sindhuli, Rukum and Sunsari districts; Dalits were covered from Bajhang and Achham
districts. Similarly, with respect to terai ethnic groups, Muslims were covered from Parsa,
Rautahat and Sunsari districts whereas Madhesi were interviewed in Parsa, Rautahat and
Dhanusha districts.
Two Village Development Committees (VDCs) from each research district were selected
depending on the higher concentration of a specific ethnic group (Dalit, Muslim, Janjati and
Madhesi) in the district. Available Central Bureau of Statistics (CBS) 2011 data were used for
selection of the VDCs. The ethnic group targeted for investigation was located upon reaching
the VDC.
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
2.3 SAMPLE AND SAMPLING STRATEGY
Initially, a list of pregnant women and mothers of newborn children below two years old
in that community was prepared with the help of Female Community Health Volunteers
(FCHV). Separate sample frames of eligible mothers (pregnant mother, adolescent mother,
adult mother) of the targeted ethnic group were developed from that list; these were requested
to participate in the research process. The list of fathers and mothers-in-law was similarly
developed and they too were invited to participate in the research.
Maternal Child Health Workers (MCHWs)/Auxiliary Nurse Midwifes (ANMs) were selected
as the health workers from SHPs/HPs of the identified VDC to be contacted for in-depth
interviews. In their absence or unavailability, s/he was substituted with the person in charge of
the health facility or Village Health Worker (VHW).
The SHPs/HPs were contacted to obtain the list of FCHVs in the selected VDC. The FCHVs
residing in the research location were requested to participate in the study if s/he were
unavailable the FCHV in the list was requested. In the case of traditional healers, the most
popular recommended by the ethnic group were interviewed.
Similarly, a representative from Health Facility Management Committee, School Management
Committee and most influential religious leader of the ethnic group were requested for
interviews.
In-depth interviews of community leaders (mukhiyas, manyanjans, respectable community
persons) from each ethnic group were conducted, as appropriate.
Two media personnel, one each from the electronic and print media in each district, were
interviewed. Moreover, additional stakeholders such as a representative of the Ward Citizen
Forum, Nutrition and Food Security Steering Committee, District Agriculture Livelihood
Officers or Dalo (agriculture and livestock) and model farmer were interviewed as
appropriate.
2.4 FIELD RESEARCH TIME PERIOD
The research was conducted from May to June 2014.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
5
Table 1 Target Audience and Sample Size in Hill Districts
6
Audiences
Bajhang
Achham
Rukum
Sindhuli
Women with children 24
months and under (Dalit,
Janajati, Muslim, Madhesi)
6
6
6
6
Husbands (Dalit, Janajati,
Muslim, Madhesi)
6
6
6
6
Mothers-in-law (Dalit, Janajati,
Muslim, Madhesi)
6
6
6
6
Health care workers/FCHV,
Pharmacists, Traditional
healers
6
6
6
6
Health Facility Management
Committee, School Management Committee, Religious
Leaders
6
6
6
6
Community leaders
4
4
4
4
Media
2
2
2
2
Additional Stakeholders –
Civil Society, Shop Owners,
Private Sector
4
4
4
4
Shop Observation
4
4
4
4
Total
44
44
44
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
Table 2 Target Audience and Sample Size in Terai Districts
Audiences
Parsa
Rautahat
Dhanusha
Sunsari
Women with children 24
months and under (Dalit,
Janajati, Muslim, Madhesi)
6
6
6
6
Husbands (Dalit, Janajati,
Muslim, Madhesi)
6
6
6
6
Mothers-in-law (Dalit, Janajati,
Muslim, Madhesi)
6
6
6
6
Health care workers/FCHVs,
Pharmacists and Traditional
healers
6
6
6
6
Health facility Management
Committee, School Management Committee, Religious
leaders
6
6
6
6
Community leaders
4
4
4
4
Media
2
2
2
2
Additional Stakeholders – civil
society, private sector, shop
owners
4
4
4
4
Shop Observation
4
4
4
4
Total
44
44
44
44
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
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2.4 RESEARCH PROTOCOL AND DATA COLLECTION
TOOLS
On completion of the pre-assessment report, core research team members developed the
research protocol and research tools in English. These were translated in the local language
and dialects, pre-tested, revised and finalized accordingly.
2.5 RECRUITMENT AND TRAINING
Thirteen field researchers (nine females and four males) were recruited for data collection.
They were trained for five days utilizing the training manual developed by the core technical
team members. The training included both classroom and field training. The curriculum
covered: background, content, purpose and objectives of the study; research tools – in-depth
interview guide, observation checklists to be used for data collection with different categories
of respondents; and an explanation of the Discussion Guides (DGs) and their links with the
research objectives.
Nutrition and research experts from Another Option and Right Direction Nepal (RDN)
conducted the two-day classroom sessions to clarify all aspects and areas of the enquiry with
the entire research team members responsible for the successful completion of the research.
The third day was devoted to field training followed by pretesting of tools, which took place in
Bhumi Dada Village Development Committee (VDC) ward number four of Kavrepalanchock
district. Each field team member conducted an in-depth interview with the primary audience,
another with the secondary audience and one key informant interview with shopkeepers. All
interviews took place under the guidance of the supervisors. Thereafter, a review meeting was
held with field team members to share field experiences and lessons learned. The interviewers
commended the remarkable learning experience, expressing confidence in their ability to
undertake the interviews as intended.
The core team discussed in detail the feedback on the tools and the comments received from
the field staff as well as observations from supervisors that monitored the pre-test process.
Inputs and suggestions were noted and the tools were modified based on pre-test results.
However, the modifications were not significant; only the sequence of the questionnaire was
revised and some minor language changes were made for logic and appropriateness. Field
team members were reoriented in the revised tools before their departure to the field. Mock
call interviews and discussions were conducted and issues were shared and clarified with all
field researchers.
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
2.6 DATA COLLECTION AND ANALYSIS
The recorded interviews were transcribed verbatim in Nepali language and the transcripts
reviewed by core research team members to ensure quality of transcription. The core team
members developed major themes and sub-themes and they were elaborated as appropriate
by reviewing the major research questions and transcriptions. Each transcript was carefully
read, with researchers looking for particular patterns, themes, concerns or responses posed
repeatedly by the participants. Similar major themes were further merged under a single
primary theme narrowing them down to a feasible number. If needed new themes
were created.
Color coding was applied by coders in close consultation with core team members to
differentiate themes and ensure the consistency of information and association under defined
themes and sub-themes. The multiple coders/experts were properly oriented on the objective
of the research, data collection tools, themes and sub-themes before data coding and entry.
Text and information were reviewed rigorously to ensure accuracy in identifying the link and
connection of the responses with the defined themes and sub-themes.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
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C H A P T E R
3
FI ND I NGS
3.1 VALUES AND ASPIRATION
The key driving aspirations for the four ethnic groups are the desire for improved livelihoods
and a better lifestyle. They yearn for the enhanced opportunities afforded by internal and
foreign travel. One of the more remarkable observations during this study was the absence
of males from the communities. Entire villages are almost devoid of males, most of the men
are in the Gulf States, India or urban areas in Nepal working to earn a living for their families.
Their remittance provides the basic necessity and financial stability for the rest of the family
back in Nepal.
“I want to work hard so that my family can have good food, my
children grow healthy and I can have a small house and buy
some land to do some agriculture”
– Father from Achham
Almost all mothers accord a high value to their children’s education. They believe that a sound
education is a passport to a much more rewarding, more stable life. An education would help
them secure better employment than their fathers’. They therefore aspire to send their children
to private schools. This sentiment is repeated by mothers-in-law also. Mothers want their
children to become doctors or engineers since these are among the most respected professions
in Nepal.
The following quotes of mothers from three different ethnic groups and regions highlight the
similarity of their aspirations for their children.
“I want to educate my children and make them prosperous like
doctors and engineers are.”
–Janajati mother from Sunsari
“I want to make my son a doctor.”
– Madhesi mother from Parsa
“If my husband earns well, I have a dream of providing good
education and making him [her son] a doctor.”
– Dalit mother from Achham district
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
“I have a dream of making my baby a doctor.”
—Dalit mother from Bajhang district
Women left their homes to work to earn income. Men left home seeking better opportunities.
In their discussions about family aspirations, fathers, mothers and mothers-in-law made no
connection between the “value” or health benefit of correct (exclusive) breastfeeding practices
and their aspirations for themselves and their children, i.e., education, success, security.
The economic impact of having sick children and babies because of malnutrition due to
incorrect breastfeeding practices is not understood among these communities. They fail to
appreciate the extent of the future health burden their families will experience resulting from
under nutrition in early childhood. The World Bank’s Database (Nepal, 2012) shows the outof-pocket expenses for health-related issues at 41.7 percent. It has been increasing annually.
The audiences are unaware of the small “doables” that are within their ability to do that will
help to reduce these expenses and assure healthy developed children. These doable actions also
can significantly contribute to their reaching their aspirations.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
3.2 FEARS AND CONCERNS
Most fears and concerns are related to the uncertainty of their livelihood, economic and
financial insecurity, or societal marginalization. Most of these concerns are attributable to
social, political and cultural norms that limit their educational opportunities, access to quality
healthcare, and are derived from overall caste and gender bias including social exclusion.
“One of the concern in my life right now [is] my children’s
don’t go to school, are unwell at times, how will they grow,
when will they grow up when to educate them, when to send
them to school, I keep on thinking about when will they grow.
Right now we do not have anything, we are very poor, and we
don’t even know if we may be able to educate them, I see people
sending their children to school. Rich people send their kids to
boarding school, I think I might not even be able to send them
to government school, we don’t have money. I keep on thinking
about how and what to educate them”
– Mother from Dhanusha
All four communities, especially the hill region Dalits, are concerned about food and nutrition
insecurity in all its dimensions – unavailability, inaccessibility, unaffordability and instability.
Dalits and Janjatis are frustrated by having to work in the fields approximately 18 hours a day
with only an annual harvest that produces a food supply for less than two months. Janjatis in
the past have been affected by flood damage to crops and inadequate markets.
“I have no food at home. I have a child. I wait outside my
neighbor’s house so that she will give me the left over and I can
feed my child and if something is left, myself too”
– mother in Bajhang
Men are worried about the inability of finding employment without going outside the village
where there are better income-earning opportunities. Lack of skills and education create
difficulty in finding decent paying employment. Men also recognize that their lengthy and
frequent absence from home is a source of grief, anxiety and sadness, especially to their wives.
Many wives echo the desire to have the family living together; at the same time they wish their
husbands earn a decent income. This poses a dilemma, since good job opportunities in their
communities are rare.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
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Education – access, quality and universality – is another major concern among all the ethnic
groups. Gender bias in providing education is seen as more pronounced in Muslim, Madhesi
and Janjati communities. Fathers told the researchers that they are eager “to get rid of their
daughters” and that since young brides require smaller dowries, this is an economic incentive
for early marriage. More highly-educated females meant parents must find a more educated
groom, requiring a larger dowry package.
The practice of child marriage is more common among Madhesi and Muslim communities
and rare in Janjati and Dalit populations. There is also the practice of multiple marriages
which is prevalent in the Muslim community; estimated to be common in about 25 percent
of the Muslim community.
“In this community almost 25 percent of males have married
more than once and if men earn more money they tend to
marry more and also when the wife is not obedient toward
their husband.”
—School Management Committee member, Muslim community
In the terai region, quality higher education is only available in larger, more distant towns and
therefore inaccessible and unaffordable. Additionally, Dalits seeking higher education in larger
towns, face discrimination to obtain accommodations.
Health and health care – accessibility, affordability and quality - are a concern to all
communities.
Children’s illnesses – diarrhea and pneumonia – are a source of worry to parents.
The gender of health care providers is sometimes an issue especially in Muslim communities.
All four communities are worried about the unbudgeted expenses that arise when family
members fall ill. Terai Muslims prefer to visit health facilities in distant towns or India
and they worry about the cost of the travel and treatment. For the Dalits and Janjatis
the traditional healers are very influential. These populations express concern about the
inadequate service in the health posts and unavailability of the right medicines. Therefore,
they prefer going to the pharmacist which means incurring higher costs and longer travel.
Women are concerned that they have a limited or no role in decision-making. They worry too
about rejection for being seen as acting differently or going against traditionally held beliefs
(especially relevant to breastfeeding and complementary feeding practices). The women’s
excessive work load reduces the time for child and mother care. These mothers also feel they
are in no position to complain. In Muslim communities, daughters-in-law are not generally
supported by their mothers-in-law and even husbands. Generally, they are not allowed to
work outside the home – rigorously adhered to in Muslim and Madhesi communities, less so
in Janjati community.
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
Verbal and physical abuse of women is still prevalent in the Dalit community especially when
men are drunk. It was observed in one interview, when the mother-in-law was in the room,
the mother did not respond to the questions and gestured quietly about the mother-in-law
being in the room.
Dalit mothers in hill regions are concerned about having to walk a long distance to fetch clean
water to use for drinking and cooking. They complain about the difficulty in maintaining
personal hygiene, having to go all the way down to the river for a bath or to wash their clothes.
These same hygiene concerns apply to their caring for their children. Washing and cleaning
of their children took a lot of time and energy. The interviewers observed incidents where the
children suffered significant skin problems.
In the terai region, it is generally easier to produce ingredients for preparing complementary
foods from home garden and farming. However, there are real concerns about excessive rains
and flooding in the monsoon season that impact food production and loss of livelihoods.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
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3.3 BREASTFEEDING
A key finding is the observation that the presumed knowledge about the value of breastfeeding
has not resulted in correct breastfeeding behavior. The study indicates a high-level of
familiarity with breastfeeding but that each ethnic group introduces its own customs and
practices as well as interpretation of what and how to breastfeed correctly. There is high
frustration among mothers and mothers-in-law with breastfeeding. Common comments
included: takes up too much time, it is painful, baby does not want it, and there is little or
no milk.
There is also tension between health care workers and mothers: “mothers won’t listen” and
“they think they know everything” are common complaints by health workers. Messages and
training has focused on the “how” of breastfeeding. Most mothers interviewed could recite
perfectly the cultural practices specific to their community. They could not relate the value of
breastfeeding to their long-term aspiration for their children’s life to be better. Nor did family
members understand that breastfeeding could minimize health expenses now and as children
grew older or that compromises made in breastfeeding practices could contribute to health
issues later on.
The Madhesi community feed babies honey and goat milk because there is a general belief
that mothers do not produce milk for the first two days following birth. There is a strong
belief in the Madhesi community that goat milk is more nutritious than mother’s milk.
Similarly a Dalit mother expressed her fear of giving colostrum to a newborn for fear of
adverse effects, because that is the general belief in the community. A traditional healer from
Janjati community said “the first milk is dirty, that affects the newborn as well, so it is better to
throw this away, then to feed the child”.
Mothers also experience the constraint of not producing enough milk for babies because
of their state of ill-health. The women are concerned about being marginalized for acting
differently or going against traditionally held beliefs. This is especially an issue when the
husbands are working outside Nepal and the wives feel they do not have any support.
The heavy workload in the house reduces the time and space to breastfeed the child at regular
intervals. Mothers have to leave home for work, leaving the babies behind and therefore could
not continue to exclusively breastfeed. In the Janjati community, the child is given few drops
of alcohol along with cooked rice water within 15 days of birth to reduce their crying when
mothers were out at work.
“My baby breastfed for three months, then I got pregnant
again, the milk production became low so I stopped”
– mother from Muslim community
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Mothers in Janjati, Dali, and Muslim community said that they should not breastfeed their
baby if they fell ill because they believe that the baby would be infected.
Studies conducted by UNICEF and UNESCO repeatedly show the correlation between girl
education and adopting positive health behaviors. Health care workers point out that it is
easier to convince an educated mother to practice exclusive breastfeeding. There is also a
perception that if the daughter-in-law goes outside of the home, she will be influenced by
others and that is strongly discouraged.
“If she meets different people, she might get influenced by them
which might lead to uncomfortable situation at home”
– a Madhesi mother-in-law expressing her thoughts
This fear has resulted in mothers not participating in meetings or programs that could raise
awareness on breastfeeding as well as other health-focused activities.
There is a practice propagated by a segment of fathers, mothers-in-law and health workers
to introduce water when exclusively breastfeeding – in some cases as early as the third day. In
addition to the exclusive breastfeeding taboo, the purity of the water being given to infants is
in questions so the positive benefits of breastfeeding could be compromised by using
unclean water.
Impure water is a leading contributor to diarrhea. This research shows the two biggest health
concerns of mothers for their children are diarrhea and pneumonia. Mothers and families
reportedly do not make the connection between exclusive breastfeeding, introduction of
impure water, and diarrhea.
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3.4 COMPLEMENTARY FEEDING
The first complimentary food that is introduced when children are six months or even earlier
is usually not nutritionally adequate. In the terai region where shops are more accessible, they
usually start with biscuits and horlicks. Mothers claim that they provide biscuits on the advice
of some doctors, so they are convinced that this best for the babies. The mothers say that the
babies prefer the taste of biscuits. The mothers also claim that the infants do not like the taste
of homemade complementary foods (lito) or dal bhat (rice and lentil) when compared to
the biscuits so it is easier to feed them biscuits. It also is less time consuming to prepare the
biscuits than other homemade foods.
Sometimes babies suffer diarrhea when fed lito for the first time, so the mothers believe it is
not good for babies. Another reason that the mothers do not mention is that lito which is
made with water may have been prepared with contaminated water that contributed to the
child being ill.
Commonly used complementary foods are either homemade ‘sarvottam pitho’ or commercial
foods like Cerelac made in India or the commercial sarvottam pitho made in Nepal. Soy,
wheat, grams, rice and maize are the most commonly used ingredient in these products. The
ingredients are roasted, grounded and then stored. This mixture can be eaten directly without
recooking but mothers usually roast them again, mix them in sugar and water and feed the
mixture to the babies. On the other hand, the commercial preparations are just mixed with
water, tea or milk and given to the babies.
The commercial foods, when available, are very expensive but generally are inaccessible. They
are very seldom used in the hills. In the terai, even though accessible, they are unaffordable
to most. One shopkeeper in Rukum and two in Sindhuli explained that most people prefer to
buy the expired commercial complementary foods or those very close to the expiration date
because they are less expensive.
Other cooked complementary foods given to babies include, jaulo (rice and lentil cooked
together), mad (adding water to rice), halva (mostly using semolina) and khichdi (prepared
by adding water in rice). Mothers admit having limited knowledge about preparing special
recipes for children using locally available ingredients. The biggest key constraint, explained
by the mothers, is the time it takes for food preparation. This is especially difficult where time
is already limited by other responsibilities. The mothers have limited knowledge about the
importance of good complementary feeding for children’s growth and development.
Twenty-nine percent of Nepali babies have access to a diverse diet. The majority of babies do
not eat a variety of foods or from all the food groups, i.e., grains, roots and tubers, legumes
and nuts, green vegetables, animal source foods and fruits that are generally available. They
are usually feed dal bhat (lentil and rice) with some potatoes. In the terai, Madhesi mothers
complained that the babies do not like the taste of the available vegetables like spinach, lady
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
finger, beans explaining “they are not tasty”. They maintain the babies only like the potatoes.
Animal products and fruits are neither affordable nor accessible. Additionally, family members
indicate that the animal products and fruits are not digestible by babies. The children in the
community often suffer from diarrhea when served meat so they were not convinced about
the value of giving to their children. In the case of a Dalit community in the hills, the mothers
said that in the absence of rains there is no water to grow vegetables and they could not afford
to buy vegetables.
“I sprinkled the micronutrient powder in the dal bhat and gave
it to my child but he did not like the taste and vomited all the
food – I have stopped giving it”
—Dalit mother
There seems to be inadequate knowledge of using the micronutrient powders (MNP).
One of the observations made by the interviewers is that most of the time mothers are very
busy and often babies are fed by other members of the family. There is very little interaction
with the child during feeding to teach and stimulate social development as well as encourage
the child to eat. Dalit women from Bajhang remembered her husband’s word “the cattle are
running, there is no grass for the cows, hurry up, you don’t have to spend the whole day feeding
the child.”
They do not understand the value of or have the luxury of time to practice responsive
feeding. This practice helps a child to develop good eating habits and also helps the
mother to recognize what her child likes to eat.
Another observation was the minimum practice of good hygiene while feeding the child.
Feeding is often done outside the house with flies sitting on the babies’ food and face. In
addition, mothers rarely wash their hands before feeding the babies. Utensils are dried in
the open and are covered in flies. These utensils are not washed again using clean water
before feeding the child. Mothers were surprised when interviewers spoke about the
relationship between malnutrition and hygiene and sanitation. They only link malnutrition
with food intake.
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3.5 SOURCE OF INFORMATION
A large proportion of husbands and fathers work overseas, particularly in India. In some
populations, the Dalit, their wives and families visit them there. Sometimes, the men return
with ideas and opinions that reflect their exposure to different ways of living. Though
being away causes hardship – some households are totally dependent on this income to
buy essentials including food. A key benefit is better access to information and exposure
to practices that enhance their aspirations for their lives and their children. Fathers talked
about traveling to India to receive better health care and return with medicines and have had
exposure to complementary foods.
The health workers and FCHVs provide information on maternal health, family planning and
breastfeeding to mothers during Antenatal Care (ANC), delivery and neonatal periods. They
provide information on complementary feeding during Post Natal Care (PNC), Expanded
Program of Immunization (EPI) and Growth Monitoring Program (GMP). The mother
receives generic messages but no counseling is given based on the practices and barriers of the
specific community regarding the above health related matters. Also, mothers would receive
generic information during the mother’s group meetings that are conducted every month in
the community by the FCHVs, if they are allowed to attend.
Some health workers expressed frustration in their interventions because the women are just
unwilling to listen to what they have to say. In such situations, they try to convey the same
messages through the FCHVs at their monthly mothers’ group meetings. Usually, these
meetings focus on three topics: health, nutrition and immunization.
Health workers receive training in several areas at the District Health Hospital. The DHO
always organize training sessions on any new topic being introduced. They have received
training in the areas of nutrition, breastfeeding, complementary foods and on CMAM.
ANMs have received very useful training from SUAAHARA the USAID-funded Feed the
Future Program. It has helped them to understand the importance of breastfeeding and
complementary feeding for babies.
“The trainings are very useful and our messages to the mother
are gradually working. They have the mothers’ breastfeeding
babies right after birth. In addition, newly delivered mothers
are bathing within 24 hours after the delivery”
The terai has and continues to have a strong influence from India. Additionally, Nepali and
Indian media sources provide access to a wide-range of popular culture, health news, and
information on personal care. Mass media channels, web-based (internet) communication,
and social media are pervasive in the terai but less common in the hills. Though the hills have
been and continue to be less connected, villagers do have access to mobile phones. Data from
2011 show 71 percent of Nepali’s have mobile phone subscriptions.
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
Local FM stations (60 percent) seem to be the most effective mass medium to reach the target
audience followed by interpersonal communication with family and friends (50 percent) and
FCHVs/influentials (30 percent). Whereas the most trusted sources for health information
were doctors/FCHVs (80 percent) followed by traditional healers (60 percent), then family
and community leaders (50 percent) and FM station (30 percent).
Radio is the most prevalent mass media communication channel in the hills. In the terai,
social media is prevalent as well as videos and internet for instruction, information, and
entertainment. The local FM is a very popular radio program and mothers get many health
messages from them.
The research shows that the village mukhiyas and manyanjans are influential and the
traditional healers are visited more often than health workers. They also have a high trust
level (60 percent) by the families. At the household level across the population it is generally
the mother-in-law who makes decisions about complementary feeding. Fathers see their
roles more as bread winners and do not interfere in breastfeeding or complementary
feeding matters.
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
A N N E X
A
E C O L O G I C A L MO D EL TH EOR Y FO R
B E HAV I O R C HA N G E C OMMU N ICATION
Audiences – Gender Equality Nutrition in Nepal
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
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A N N E X
B
B I B LIO G R AP HY
FR O M AN O T HER OP TION ’ S
AS S E S S M E N T REP OR T
This bliography is for the principle secondary research Another Option reviewed as part of its
assessment to design the qualitative research for the World Bank’s activity, Gender Equality
and Social Inclusion for Food- and Nutrition-Security in Nepal.
2012 UNICEF Report: “Analysis of trends in nutrition of children and women in Nepal”
Jennifer Crum, MPH, John Mason PhD, Paul Hutchinson, PhD; Tulane University, School
of Public Health and Tropical Medicine
Alive and Thrive Project www.aliveandthrive.org
Ecological Foundations of Health Promotion (1996). Lawrence W. Green, Lucie Richard, and
Louise Porvin. American Journal of Health Promotion: March/April 1996. Volume 10, No. 4,
pp. 270-281.
Family Planning, Maternal Newborn and Child Health Situation in Rural Nepal: A Mid-term
Survey for Nepal Family Health Program (NFHP) II (2010)
Gender, caste, and ethnic exclusion in Nepal: Following the policy process from analysis to
action. 2006 Lynn Bennett, The World Bank.
Government of Nepal, Department of Health Services (DoHS), (2012-13). Annual report of
department of health services
Joshi, N. et al. (2012). Multivariate analysis of main determinants of non-optimal
complementary feeding, using 2006 DHS data
Karkee R, Jha M, (2010). “Primary health care development: Where is Nepal after 30 years of
Alma Ata Declaration?”
Kenda Cunningham, Suneetha Kadiyala, (2013). Summary SUAAHARA baseline survey
report
Linkages Project website (www.linkagesproject.org)
Mathur S, Malhotra A, Mehta M. Adolescent girls’ life aspirations and reproductive health
in Nepal
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
MoHP (2013). Health sector strategy for addressing maternal under nutrition 2013 – 2017
NPC, CBS, WFP, WB, US AID, UNICEF, (2013). Nepal thematic Report on Food Security
and Nutrition
Nepal Household Survey, (2012). Nepal Health Sector Program II. Dr. Suresh Mehata,
Dr. Sushil Chandra Baral, et al.
Patel, Archana, Dr., Dhande, Leena, Dr. (2011). “The Evaluation of the Effectiveness of Cell
Phone Technology as Community Based Intervention to Improve Exclusive Breast Feeding
and Reduce Infant Morbidity”, mHealth Summit (January 2012).
Review of Policy, Strategy, Program interventions and Evidences for Reducing Health and
Nutrition Inequities (Draft), 2014. Save the Children.
Right Direction Nepal (2012) Formative research on strengthening access and utilization of
immunization services in eight terai districts of Nepal
Rich Magnani, Anahit Gevolgyan Kathleen Kurz, (2012). Market analysis of complementary
food in Nepal (NCRSP 2012)
Socio-demographic Features of Mothers in Relation to Duration of Breastfeeding in Manipal
Teaching Hospital, Pokhara, Nepal, (2012). Basnet, S., Gauchan E., Malla K., Malla T., et al
Singh, J. Kathmandu Academy for Educational Development, (1998). Literature review of the
practices and beliefs regarding maternal and infant/child nutrition in Nepal
SUAAHARA, USAID (2013). Formative research Report (SUAAHARA)
UNFPA, HERD, (2013), Perception Survey 2013
Health Sector Strategy for Addressing Maternal Under-Nutrition in Nepal (2013-17)
Food Utilization practices, beliefs and taboos in Nepal an overview – Dr. Ramesh Kant
Adhikari May, 2010
Formative Research Report/SUAAHRA/USAID – February 2013
Multisectoral Sectoral Nutrition Plan for Nepal – February 2012
Accelerating Progress in Reducing Maternal and Child Undernutrition in Nepal –
Karen Codling, World Bank Consultant – June 2011
Strategy for Infant and Young Child Feeding in Nepal (2013-2017)
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
29
Nepal Nutrition Assessment and Gap Analysis (2009)
Understanding the Access, Demand and Utilization of Health Services by Rural Women in
Nepal and their constraints – World Bank - June 2001
University of Tampere /School of Health Sciences
Situ K.C: Women’s Autonomy and Maternal Health Care Utilization in Nepal; Master’s Thesis
Learn and Sharing Series 2 – HELVETAS: Empowering Women
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GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
A N N E X
C
KE Y F I N D I N G S
FR O M AN O T HER OP TION ’ S
AS S E S S M E N T REP OR T
Key Findings from Desk Review and Secondary Research
AssessmentAnother Option’s Assessment Report,
March 2014 for The World Bank
The information illustrated below were collected from the various secondary research and
documents available with a primary desk review and are categorize by different themes that
may be relevant to the qualitative study.
VALUES AND ASPIRATIONS
STUDY/REPORT
FINDINGS
Baseline Survey
SUAAHARA 2012
These are the findings of economic events which may be associated values
and aspirations; Educational scholarship for a child 26 percent and new
or increase in remittance 13.1 percent are two most common positive
economic events followed by new job of household member 5.3 percent.
Adolescent Girls’ Life
Aspirations and
Reproductive Health
in Nepal
Study shows that adolescent girls in these communities have dreams and
aspirations for a better future and adults acknowledge and support these
ideals. However, social norms and institutions are restrictive, especially for
girls, who are often unable to realize their hopes for continuing education,
finding better-paid work or delaying marriage and childbearing, and this
directly impacts reproductive outcomes.
Urbanization and remittance income have become drivers of poverty
reduction and improved nutrition and food security
Nepal Thematic Report
on Food Security and
Nutrition 2013
The proportion of female-headed households has almost doubled since
1995/96, and women are spending more time engaged in agricultural work,
while young people are shifting their time use towards education and income
generating activities
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
31
FEARS AND CONCERNS
STUDY/REPORT
FINDINGS
Baseline Survey
SUAAHARA
These are the findings of economic events that may be associated as fear
and concerns short-term illness 27.4 percent; loss of crop from weather 23.9
percent; loss of crop from other regions 18.2 percent; loss of livestock/poultry
18.2 percent; Loss of cattle 14.9% percent; accident/ injury 5.8 per cent;
chronic long-term illness 3.1 percent.
BARRIERS AND GAPS
STUDY/REPORT
FINDINGS
One mother reported belief by some women that breastfeeding causes loss
of beauty, particularly the shape of the breast
Helen Keller International
(HKI) Action Against
Malnutrition through
Agriculture (AMMA)
Project - Baitadi
Market Analysis of
Complementary Food in
Nepal – NCRSP 2012
32
Widely held view that breastfeeding should cease immediately upon becoming pregnant again, because of loss of nutrient value of the milk and likelihood of causing sickness
A majority of respondents could think of no obvious benefits for the mother
but had negative impact since she is giving blood to her child so that would
make the mother weak
An underestimated constraint on child feeding is that the child’s food
preparation takes a lot of mothers’ time, which is often already limited by
other responsibilities
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
STUDY/REPORT
FINDINGS
One widely held belief is that if a woman eats more during pregnancy she
will have a bigger baby which can cause problems during labor
Literature Review
of the Practices and
Beliefs Regarding
Maternal and Infant/
Child Nutrition in Nepal,
Singh, J. Kathmandu,
Academy for Educational
Development, June 1998.
Social factors also influence the diet of pregnant women: women and girls
usually eat after male members and children have eaten and have less access
to food from animal sources and other special foods
Recently delivered mothers considered impure and not allowed to eat with
other family members until the purification ceremony - mothers’ food intake
limited during this period in some communities
Women in mid and far western hill regions practice a system in which the recently delivered women are kept in the cowshed outside their homes in very
unhygienic conditions
In some cultures, belief of a connection between stomach and womb is the
basis for resting both by not giving food to the mothers.
A range of issues impacting maternal under-nutrition has been identified to
be addressed under the Health Sector Strategy 2013–2017
Health Sector Strategy
for Addressing Maternal
under Nutrition
2013 – 2017
• Early marriage —early pregnancy and child bearing
• Large family size (less attention to adolescent girls)
• Low priority and status of girls
• Low school enrolment, attendance and drop-out of girls
• Inequitable intra-household food distribution
• Pregnancy is not considered a special condition for more attention and care
• Low priority given to women compared to other family members with
regard to their dietary and health needs
• Inequitable intra-household food distribution
• Frequent child bearing
• Food taboos, beliefs and practices. There are taboos surrounding
foods being hot or being cold. Foods like pumpkin and spinach are not
eaten because they are cold foods. Also, women eat less when they are
pregnant because they believe that the less you eat the smaller the baby
and easier to deliver. Finally, women eat last and eat what is left over after
everyone (husband, mothers-in-law, and children) has eaten.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
33
STUDY/REPORT
FINDINGS
Pregnant reported that they visit health facility with mother-in-law, other relatives, husband, main barrier to getting ANC is shyness
Formative Research
SUAAHARA 2012
Family planning is generally viewed as a women’s concern, men usually have
little involvement
Husband and family members opposed a women using of birth control if she
had not yet produced a son
Mother-in-law source of information regarding child feeding, child care and
food during pregnancy.
ACCESS AND AVAILABILITY
34
STUDY/REPORT
FINDINGS
Primary Health Care
Development: Where is
Nepal after 30 years of
Alma Ata Declaration –
Karkee R, Jha M
Out of 75 districts, 60 have district health offices, 65 have district hospitals,
and 15 have district public health offices. There are 209 PHCC (0.8 PHCC per
100000 population), 677 HPs, 3126 SHPs, 15257 TBAs and 48445 FCHVs.
This has resulted in 12-fold growth in health facilities during 1992-1996. Sixty
two percent of people have access to HP/SHP within half an hour of travel on
foot
Annual Report of
Department of Health
Services 2012/13
This report is mainly based on information collected by DoHS’s Health
Management Information System (HMIS) from health institutions across
Nepal. A total of 95 public hospitals, 205 primary health care centers (PHCCs),
822 health posts (HPs) and 2,987 sub health posts (SHPs) reported to HMIS
in 2012/13. Similarly 12,821 primary health care/outreach clinics (PHC/ORC),
16,646 Expanded Program of Immunization (EPI) clinics and 48,897 Female
Community Health Volunteers (FCHVs). A total of 445 NGO and 476 private
health institutions also reported to HMIS this year.
Formative Research
SUAAHARA
Work load and distance to the place of their work hinder breastfeeding
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
STUDY/REPORT
FINDINGS
Baseline Survey
SUAAHARA
Less than half of newborns received check-ups within two days of birth.
When children suffered from diarrhea, families visited the pharmacy and subhealth post most frequently (41 percent and 28 percent respectively). Likewise, for fever/cough, 38 percent and 22 percent visited the pharmacy and
sub-health post, respectively
Baseline Survey
SUAAHARA
Mothers consult FCHVs, but the FCHV’s current strength appears to be
in delivering interventions that are product driven, for example, vitamin A
supplementation and deworming. Their role in postnatal and newborn care
is not strong in nutrition and health behaviors the survey shows very poor
knowledge and capacity of FCHVs in the realms of health and nutrition.
Recommendation was that SUAAHARA and the government of Nepal needs
to make heavy and rapid investment in strengthening the existing FCHV
system as well as other systems of community mobilization and outreach
through interpersonal communication to deliver high quality maternal and
child health and nutrition services.
TRUST AND DISTRUST
STUDY/REPORT
FINDINGS
FCHVs stand out as the focal person relating to child health that parents
contact within study districts. In the quantitative study, FCHVs were by far the
chief source of information (over 90 percent of the cases) for both routine immunization as well as National Immunization Day (NID) campaign.
Formative Research on
Strengthening Access
and Utilization of
Immunization Services
in Eight Terai Districts of
Nepal
FCHVs also surface as the most trusted (93 percent) source of interpersonal
communication; they are one of the most important influential figures relating to child immunization in rural settings
At community level, prominent individuals/leaders in most communities are
mukhiyas and influentials in the Dalit community are called manyajans and
they can help sway immunization participation. In most marginalized communities in the three districts investigated, there are group leaders, manyanjans who are respected figureheads in their respective communities and their
words are universally accepted.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
35
ECONOMIC/WORK/AFFORDABILITY
STUDY/REPORT
FINDINGS
Breastfeeding not practiced exclusively for the first six months due to their
low breast milk production resulting from inadequate dietary intake, sickness,
excessive household chores and early return to work affecting mother’s
health.
Helen Keller International
(HKI) AMMA Project Ghee, meat, and milk are considered good for new mothers for breastBaitadi
feeding –
Most lactating mothers, unable to afford special foods, consume the usual
family diet
Soap was seen as luxury and expensive item
Formative Research
SUAAHARA
Heavy household chores made it difficult to pay attention to household
hygiene
GENDER ISSUES
STUDY/REPORT
Formative Research
SUAAHARA
36
FINDINGS
Fathers not being involved in taking care of the child because it is traditionally
perceived as a women’s work so it is not fit in the society for male
involvement
Women have limited decision making power regarding infant feeding
practices as it is often influenced or made by the mother-in-law or the father,
which is a reflection of their low status
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
STUDY/REPORT
FINDINGS
Seven percent of parents who want to marry their daughter before the age
18. The key reason for doing so were because their daughter would elope 48
percent; to escape early from their responsibility 46 percent; and following
tradition 27 percent. Some of the qualitative insights for early marriages were
increasing dowry culture in terai districts, poor economic conditions, fear
their daughter will be sexually harassed.
UNFPA, HERD, Perception
Survey 2013
During FGDs in different districts both parents were asked the reasons behind
early age marriages, their responses were: desire of parents to see their
grandchildren before they get old; parents had fear that their daughter will be
sexually harassed and violated (some participants used word ‘rape’ to donate
sexual violation); male domination, fathers primarily are decision-maker
about when their daughters marry; the “misuse” of modern communication
technologies by adolescents i.e. social electronic media, mobile phones where
they get in touch with various people and easily diverted to immature love
leading to elopement and early age marriages concerned raised mostly my
mothers.
Despite the fact that it is the early marriage that poses numerous threats, a
married girl is perceived as safer from harm because it is believed that she has
a husband to watch over her.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
37
STUDY/REPORT
FINDINGS
Forty-three percent of men vs 12 percent women are empowered in the five
domains of agriculture production (decision about agriculture production,
access to and decision-making power over productive resources, control over
use of income, leadership in community and time use)
About 90 percent of women are involved in food crops production and
raising livestock however less than 20 percent of women involved in wage
and salary employments or non-farm activities. Among women involved in
household productive activities the majority report to have at least some
inputs into decision making for these activities.
Baseline Survey
SUAAHARA
The Nepal Thematic
Report on Food Security
and Nutrition (NTRFSN)
2013
Women have less control over decision-making regarding income than they
do for decision-making more generally. In food crop farming, cash crop
farming, livestock raising and fishing at least one in four report to have no
input at all in decisions on income generated
With respective to leadership, women participation in community group is
quite low. In many instances, groups do not exists even if they exist 10 to 15
percent of women are members or active members
Majority of the women report that they are not at all comfortable or have
great difficulty speaking in public
In 24 hours women resting time is on average 10 hours, eight hours work
(agriculture and domestic work), six hours spent on personal care and other
leisure activities.
The detail break down of 24 hours spent by women are: sleeping/resting
10 hrs; agriculture labor 4.2 hrs; domestic labor 4.1; care for others 2.2 hrs;
personal care (eating drinking, hygiene) 1.8 hrs; leisure including social and
religious gathering 1.2 hrs; other labor 0.3 hrs; other 0.1 [The Nepal Thematic
Report on Food Security and Nutrition (NTRFSN) 2013 reports]
38
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
REGION AND ETHNIC GROUP DIFFERENCES
STUDY/REPORT
FINDINGS
Food energy intake varied significantly between Nepal’s geographic regions per capita intake of calories highest in the rural terai - central (2,762 Kcal per
day), compared to the lowest in the rural hills - mid and far western (2,331
Kcal per day)
Areas with high levels of both inadequate FCS and food poverty include the
mountains, rural hills - central, eastern and mid- western, and rural terai –
mid western
Important disparity between stunting and wasting, also evident when
considering only the ecological zone - prevalence of stunting is highest
among the Dalits in the hills and terai, but somewhat lower among the Janjati
in the terai region; prevalence of wasting notably higher among the Janjati
than in any of the other groups; among Newars, prevalence of both stunting
and wasting lowest
A significantly higher prevalence of under-nutrition is found in rural areas
compared to urban areas
Nepal Thematic Report
on Food Security and
Nutrition 2013
Populations living in the mountains and mid- and far-western hills have
poorer food consumption and a higher prevalence of under-nutrition,
particularly for stunting.
For the poorest households, the food insecurity is highest. Under-nutrition
also improves with income, but it is noted that that it is still prevalent even
among the wealthiest households, suggesting that other factors beyond food
availability and income are influencing nutrition. The role of cultural practices
and social exclusion and their influence on utilization and consumption need
to be examined in more detail at all levels
Caste, ethnicity and religion are key determinants of food and nutrition
security
Marked differences in nutrition exist across ethnic and caste groups. Dalits
living in the terai and hill areas have the worst food consumption score,
whereas Brahmins living in the same areas have the best. In addition, the
average food security indicator scores for Dalits and Janjatis are generally
worse than the average indicator scores for any one geographical region. This
highlights the importance of providing assistance to marginalized households
living in relatively better off areas, in addition to geographically based
programs of support, to achieve national food and nutrition security
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
39
Poor educational attainment by the household head and mothers linked to
poor food and nutrition security outcomes in the findings. Literate heads
of households tend to consume a better quality diet than illiterate heads of
households. Mothers with little or no education were more than twice as
likely to have children suffering from stunting compared to children with
mothers having 12 or more years of education. Sustaining and improving
education is a priority intervention to ensure overall food and nutrition
security countrywide
Formative Research on
Strengthening Access
and Utilization of
Immunization Services
in Eight Terai Districts of
Nepal
Baseline Survey
SUAAHARA
Among different ethnic background the Dom and the Muslim population
appear to lag behind in child immunization. Misconception found in the
Muslim community is that injecting an infant/child will in the future makes
him/her infertile.
Doms are social outcasts and no one belonging to other castes/ethnic groups
visits them. Their participation in routine immunization as well as in NID is not
seen favorably by other groups which dampens the immunization efforts run
by health institutions. This group usually lives in secluded place away from
villages and their habitation is sparsely populated, which adds geographical
barrier to the existing social one.
Child stunting prevalence is the highest in the mountain areas while wasting
and anemia is most prevalent in the terai
KEY INFLUENCERS
40
STUDY/REPORT
FINDINGS
Formative Research on
Strengthening Access
and Utilization of
Immunization Services
in Eight Terai Districts of
Nepal
As outlined in the trust and distrust section FCHVs area key influencer.
The other influencers in terai are community leaders like mukhiyas, and
manyanjans (named use by Dalit community).
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
STUDY/REPORT
FINDINGS
Nepal Demographic and
Health Survey (DHS) 2011
Common information and communication devices possessed by households
are 75 percent households have mobile phones; 50 percent households
have a radio; and a similar proportion (47 percent) has a television and eight
percent households have computer (NDHS 2011).
Formative Research
SUAAHARA 2012
FCHV and traditional healers play important roles as sources of health
information because they are well known in community and often, according
to many respondents, are more convenient to access than health centers.
Many respondents said they received advice regarding the health of their
children. FCHV and traditional healers describe counseling parents on a
wide-variety of topics including nutrition, care during illness and hygiene and
sanitation. FCHV played a particularly important role in conveying information
to pregnant women about accessing prenatal care and about vitamin
supplements as well as taking children for immunization. Traditional healers
were generally consulted in the case of illness, particularly if the illness was
thought to have an underlying spiritual cause.
Multivariate Analysis
of Main Determinants
of Non-optimal
Complementary Feeding,
using 2006 DHS data
(Joshi, N. et al. 2012)
Baseline Survey
SUAAHARA
The infants of mothers listening to radio almost every day and infants of
mothers having had four or more antenatal visits had significantly higher
dietary diversity compared to the infants whose mothers had limited exposure
to media and had less or no antenatal clinic visits.
Compared with mothers with higher level of education, those having primary
level of education or illiterate reportedly risked poor dietary diversity. The risk
for inadequate dietary diversity gradually increasing with lowering wealth
index quintiles.
Mothers most preferred source of information on health and nutrition are
radio/FM 63.4 percent, FCHV 41.1 percent, health facility 39.4 percent, TV
36.6 percent, community and village gathering 8.9 percent, and mothers
group 5.8 percent.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
41
POINT OF SEEKING HEALTH SERVICES
STUDY/REPORT
FINDINGS
Formative Research on
Strengthening Access
and Utilization of
Immunization Services
in Eight Terai Districts in
Nepal
As out lined in the trust and distrust section FCHVs is one of the key
influencer. The other influencers in terai are community leaders like mukhiyas
and manyajans (in case of Dalit community).
First step of treatment was done at home. In case if the health condition
of the child did not improve and there was consistent increased episode of
diarrhea for more than two days and dangerous sign (blood in stool, watery
stool, skin wrinkles and weakness) were observed then the child underwent
second step of treatment.
Formative Research
on Zinc and Oral
Rehydration Salts (ORS)
Supplementation in the
Treatment of Diarrhea
Second step generally mothers and caretakers visited health post and
pharmacists and some visited FCHV for treatment of childhood diarrhea.
It was observed that different geographic regions responded to diarrhea
cases in different ways: in terai region children were taken to pharmacist,
in hill districts children were taken to health facility, and in Kailali District
diarrhea cases were taken to FCHV. It is to be noted that more than a half
of the respondents visited traditional healers as well as undergo allopathic
treatment at the same time. Their tradition belief is that in visiting traditional
healer will avoid an evil spell being placed on their child
In the third step if after following first and second ORS treatment the child
did not improve then child was taken to private or government hospitals for
further care and treatment.
42
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
ACCESS TO CLEAN WATER
STUDY/REPORT
FINDINGS
Ninety-one percent of the households do not treat their drinking water.
Baseline Study of Public
Private Partnership for
Hand Wash project in
Nepal
The main source of drinking water are public tap/stand pipe 32.1 percent,
Tubewell/hand pump/rower pump 31.9 percent, and piped to yard/plot 15.0
percent,
Other sources of drinking water include: unprotected spring 8.9 percent,
piped into dwelling 4.3 percent, protected spring 3.0 percent, piped to
neighbor 2.9 percent, surface water 1.5 percent, protected dug well 0.2
percent, unprotected dug well 0.2 percent, rainwater 0.1 percent
Child and Maternal Nutrition Status and Ethnicity
The World Bank activity also focuses on ethnic populations in Nepal and how or if their
behavioral practices related to breastfeeding and Infant and Young Child Feeding are different
than the majority populations. The amount of research specific to breastfeeding and IYCF
among ethnic groups is generally quantitative research (as demonstrated in the following
reviews) by specific practices. The research does not show the reasons why these practices
and behaviors are done. There was almost no quality qualitative research on the “why” of
breastfeeding and IYCF practices and behaviors. The research that has been conducted was
reviewed and found to be either incomplete or less rigorous than acceptable. The data from
the qualitative could be used as anecdotal or informational but not a basis for decisionmaking.
Several of the reports reference “Other” minority groups that may include Chepang, Jogi,
Sanyasi, Rautay and Rajhi. The minority population is specific to the districts and the Village
Development Committee (VDC) where the research was conducted.
The research for this activity will need to determine the whys that affect their decisions
related to breastfeeding and complementary feeding. Areas of focus may include the level of
education of mothers; access to breastfeeding instructions at birth or access to complementary
food products; as well as the cultural belief and practices (social norms).
Following are key findings from the research on child and maternal nutrition status upon
ethnic populations in Nepal. The interviewer reviewed the data and reports as well as talked
with experts in ethnic populations. Call sheet is included in the Annex of the Assessment
Report by Another Option for the World Bank.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
43
Nepal Household Survey – 2012
Nepal Health Sector Program II
Dr. Suresh Mehata, Dr. Sushil Chandra Baral, Dr. Padam Bahadur Chand, Dr. Dipendra
Raman Singh, Mr. Pradeep Poudel, Dr. Sarah Barnett
Early breastfeeding
Nearly half the mothers (49 percent) initiated breastfeeding within an hour of delivery (Table
1). This is similar to the NDHS 2011 finding. There were significant differences in early
initiation of breastfeeding by ecological zone: mothers from mountain districts (59 percent)
were more likely to initiate early breastfeeding than those in terai districts (40 percent).
Significant differences were also observed between caste/ethnic groups, with only 27 percent
of those in the Terai/Madhesi group initiating breastfeeding within one hour, compared to
58 percent in the Janjati group. There were no significant differences in early initiation of
breastfeeding by urban/rural residence or wealth quintile. The largest variation was seen
between castes and ethnicities: only 27 percent of those in the Terai/Madhesi group and 36
percent of the Muslim group had initiated breastfeeding within one hour, compared to 58
percent in the Janjati group.
Exclusive breastfeeding
Two-thirds of infants (aged six to 12 months) were exclusively breastfed (66 percent) for
the first five months. This is similar to the NDHS 2011 finding at 70 percent. There were
significant differences in exclusive breastfeeding by ecological zone and caste/ethnic group.
Four-fifths of infants from the Terai (80 percent) were exclusively breastfed, compared
to less than half from mountain districts (47 percent). Significant differences in exclusive
breastfeeding between caste and ethnic groups were also observed, with Muslims (92 percent)
more likely to breastfeed exclusively than Brahmins/Chhetris (55 percent). As with early
initiation of breastfeeding, there were no significant differences in exclusive breastfeeding by
urban/rural residence or wealth quintile.
44
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
Table 1: Newborn Care Practices
Category
Percentage Infants breastfed
within an hour
of delivery
Percentage
Infants bathed
after 24 hours
of birth
Percentage
Infants received
check-up before
discharge
Percentage Infants
exclusively breastfed for first five
months
All
48.5
64.7
77.8
65.9
Brahmin/Chhetri
57.2
70.7
80.8
55.3
Terai/Madhesi
other castes
26.8
70.8
87.5
83.1
Dalit
41.1
55.1
70.4
68.4
Newar
53.5
92.8
61.1
67.4
Janjati
58.4
57.7
76.3
59.5
Muslim
35.7
83.3
55.0
92.2
Other
65.1
100.0
82.5
64.4
Family Planning, Maternal, Newborn and Child Health Situation
in Rural Nepal: A Mid-term Survey for NFHP II (2010)
The study confirmed the findings of the 2006 that breastfeeding was almost universal in
Nepal. Table 2 indicates that there is hardly any difference in children ever breastfed based on
the caste/ethnicity of the mother.
Most children are likely to be breastfed on the first day of birth (87 percent). There should be
some focus on the remaining 13 percent not breastfed on the first day. In this regard, special
attention should be placed on the significant proportion of Madhesi (38 percent), Dalit (36
percent) and Muslim (28 percent) children not breastfed on the first day of their birth. This
delay could be harmful to the newborn. Table 2 reveals that these children most often receive
pre-lacteal feed and not breast milk.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
45
Table 2: Initial Breastfeeding
Category
Percentage
ever breastfed
Percentage
breastfed
within 1 hour of
birth
Percentage
breastfed within
1 day of birth
Percentage
receiving
pre-lacteal feed
Male
98.6
40.3
86.2
34.3
Female
99.7
41.3
87.4
28.5
Hill Brahmin
100.0
59.5
93.6
21.9
Hill Chhetri
99.2
51.5
99.2
15.1
Other Terai/
Madhesi Castes
99.0
24.5
61.4
68.0
Hill Dalit
98.7
45.6
96.8
12.0
Terai/Madhesi/
Dalit
99.4
17.0
63.9
57.3
Hill Janjati
99.3
37.6
98.1
14.0
Terai Janjati
98.9
43.9
88.9
27.1
Muslim
99.0
35.6
71.7
62.4
Micronutrient deficiency, termed the “hidden hunger”, can have a serious long-term impact
on cognitive development. It results from an inadequate intake of micronutrient-rich foods
and an under-utilization of available micronutrients in the diet.
There are observed gender differences in the practice of taking Vitamin A-rich foods. As
shown in Table 3, intake is higher among female children (71 percent) compared to 63
percent among males. The Table also indicates the slight influence of caste/ethnicity on the
consumption of Vitamin A and iron-rich foods by children less than three years; this appears
to be insignificant after that.
NFHP II also revealed that 80 percent of mothers with a child less than three years reportedly
received Vitamin A-rich foods in the 24 hours immediately preceding the survey, whereas
29 percent reported similarly in respect of iron-rich diet. There was no significant difference
across caste/ethnicity in terms of Vitamin A consumption. A lower proportion of Hill
Brahmin (10.8 percent) and Terai Madhesi (19.3 percent) women had an iron-rich meal
compared with Hill Janjati (49.4 percent).
46
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
The nutritional status of Nepalese children is trending upwards with a reduction in acute and
chronic malnutrition, But there is yet much to be done with certain groups: Dalits, Madhesis
and Janjatis.
Table 3 Micronutrient Intake among Children six to 35 months
Category
Percentage six
to 35 months
children
consuming
Vitamin A-rich
food last 24
hours
Percentage six
to 35 months
children
consuming
iron-rich food
last 24 hours
Percentage six
to 59 months
children given
Vitamin A
supplements last
six months
Male
62.9
22.2
92.4
Female
71.1
27.0
91.7
Hill Brahmin
70.5
12.5
96.1
Hill Chhetri
69.5
21.5
92.9
Other Terai/
Madhesi Castes
55.0
16.0
91.6
Hill Dalit
72.6
30.6
88.6
Terai/Madhesi/
Dalit
67.6
19.2
91.0
Hill Janjati
74.7
43,9
90.4
Terai Janjati
63.4
22.4
95,8
Muslim
61.9
19.2
91.2
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
47
Socio-demographic Features of Mothers in Relation to Duration of
Breastfeeding in Manipal Teaching Hospital, Pokhara, Nepal
Basnet S, Gauchan E, Malla K, MallaT,Koirala DP, Rao KS, Sedai Y, Saha R
Department of Pediatrics, Manipal Teaching Hospital, Pokhara, Nepal 2012
Most children are likely to be breastfed on the first day of birth (87 percent). There should be
some focus on the remaining 13 percent not breastfed on the first day. In this regard, special
attention should be placed on the significant proportion of Madhesi (38 percent), Dalit (36
percent) and Muslim (28 percent) children not breastfed on the first day of their birth. This
delay could be harmful to the newborn. Table 2 reveals that these children most often receive
pre-lacteal feed and not breast milk.
Table 4: Duration of Breastfeeding and Ethnicity
Ethnicity
Duration of Breast
Feeding (months)
Chhetri
41
Newar -
45
Gurung
43
Magar
44
Tamang
43
Kiranti
30
Sherpa
53
Thakali
30
Dalit
45
Muslim
30
Others
41
Table 4 highlights the duration of breastfeeding across ethnicity/caste. It ranges from 30
months for Kirantis, Thakalis and Muslims to 53 months for Sherpas; with most ethnic groups
breastfeeding between 41-45 months.
48
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
2012 UNICEF Report: Analysis of trends in nutrition of children
and women in Nepal
Jennifer Crum MPH, John Mason PhD, Paul Hutchinson, PhD; Tulane University,
School of Public Health and Tropical Medicine
The UNICEF Report advised caution in interpreting the associations between caste/ethnicity
and child nutrition outcomes. However, the data analyzed showed that Dalits had the highest
stunting prevalence and the Madhesi the highest prevalence of wasting through time.
Prevalence of both stunting (over 50 percent) and underweight (approximately 50 percent)
is highest among Dalits, Muslims and Others indicating that child under-nutrition is a
substantial problem. Analysis of wasting shows that the Madhesi group has the highest
prevalence at 23 percent, which is deemed near emergency levels. The Newar group has the
lowest prevalence of child under-nutrition for all three measures, followed by Janjati and
Brahman/Chhetri.
This analysis demonstrates the need to target nutrition interventions to caste/ethnic groups
with the largest burden of poor child nutritional status. Targeting nutrition interventions by
location and caste/ethnic group is indicated.
Table 1: Newborn Care Practices
Ethnicity
Diet Diversity
Minimum meal
frequency
Minimum
acceptable diet
Early initiation of
breast feeding
Brahmin
48.8
81.4
42.4
52.4
Madhesi
4.5
63.8
4.5
30.6
Dalit
20.1
83.4
18.9
41.7
Newar
35.2
94.1
29.3
47.3
Janjati
27.6
82.1
25.9
46.8
Muslim
11.5
69.8
6.5
35.8
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
49
Targeting by ethnic group/caste should be prioritized for the Madhesi group, which exhibited
the poorest IYCF practices considered here, followed by the Muslim and Dalit.
Prevalence of both stunting and underweight is highest in the same three groups over the
period; Dalit, Other and Muslim. Castes/ethnic groups classified as ‘Other’ have consistently
the highest estimates of stunting and underweight, though ranking changes between the two
measures for the Muslim and Dalit groups. The difference between these latter two groups
is 6ppts for stunting and 1ppt for underweight. Importantly, all of the above mentioned
three caste/ethnic groups have a prevalence of greater than 50 percent for stunting and
approximately 50 percent for underweight, indicating that child under-nutrition is a
substantial problem among all.
Analysis of wasting shows that the Madhesi group has the highest prevalence at 23 percent,
which is near emergency levels, followed by those groups with highest prevalence estimates
of stunting and underweight. The Newar group has the lowest prevalence of child undernutrition for all three measures, followed by Janajati and Brahman/Chhetri. This analysis
demonstrates the need to target nutrition interventions to caste/ethnic groups with the largest
burden of poor child nutritional status.
Gender, Caste and Ethnic Exclusion in Nepal: Following the Policy
Process from Analysis to Action
Lynn Bennett, TheWorld Bank
Many poor Dalit and disadvantaged Janjati women have little time to spare for group activities
that have benefited other women. Even when they are able to join various women’s groups,
their voices are often muted by the more confident and highly-educated women unless special
efforts are made to ensure that they participate in the governance of the group.
Critical sites of disempowerment and social exclusion may vary for different categories of
excluded people. For example, for women, the home and family is a key site where norms,
beliefs and behaviors have to be changed to enable them to exercise their agency. Community
norms and formal laws must also be changed, but change in the domestic site is fundamental.
In contrast, for Dalits, the local community is where caste-based discrimination is likely to be
most strongly enforced and harshly experienced.
A senior Dalit man is still dominant within his family despite the restrictions he faces
in the community. However, a Dalit woman who is subordinate in both the gender and
the caste domains encounters discrimination in the home as well as in the community.
Community-level discrimination against the Janjatis is much more muted and has in most
cases been effectively countered by the pride Janjatis take in their ethnic identity and in the
cultural traditions of their own group. For Janjatis, the most problematic site in terms of
empowerment and inclusion is at the level of the state - in terms of laws, policies, resource
allocation and representation.
50
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
A Review of Policy, Strategy, Program Interventions and Evidences
for Reducing Health and Nutrition Inequities (Draft)
Save the Children. January 1, 2014
The highest disparity observed was in maternal and child under-nutrition among ethnic
groups. The draft report revealed these differences: between Newars and Muslims in
proportion of undernourished or thin (BMI<18 kg/m2) were 28 percent and between Newars
and Dalits, 18 percent. The proportion of undernourished or thin among the Muslin women
(36.6 percent) was over three times higher than Newars (eight percent). The proportion of
underweight children among Muslims (31.7 percent) was over two times that of Newars (14.3
percent). The prevalence of maternal anemia among Muslims (54 percent) was over three
times higher than Newars (17.2 percent).
The analysis clearly pointed to a marked disparity in nutritional status between ethnic groups.
The regression analysis showed that Dalit children, children from Terai/Madhesi have much
higher odds of being underweight (OR 1.93) than Brahman/Chhetri, Newar, and Janjati
children (Pandey et al, 2013). The practice of breastfeeding within one hour was higher
among Newars (53.8 percent) than Muslims (33.8 percent). The gender difference in the
coverage of child health services was less than three percentage points. (Pandey et al, 2013)
There is significant disparity in the use of maternal health services across the ethnicity/caste
divide. The proportion of Newars (68 percent) accessing institutional childbirth care was
more than twice Muslims (32 percent) and almost three times more than Dalits (26 percent).
The coverage of first antenatal care among the Newars (82.7 percent) was more than twice
that of Muslims (34.7 percent). The current use of family planning methods of Muslims
(25 percent) is less than half that of Newars (63.4 percent); yet, there is no separate targeted
program to address this ethnic/caste disparity.
An equity and access program was introduced in 2006 to improve equity in access to and
utilization of maternal and newborn care. However, the disparity is still alarming. Although
additional efforts were made to mainstream those groups through micro-planning the
inequity has persisted.
For example; disparity in the coverage of institutional childbirth care between Newars and
Dalits increased from 39 percent to 42 percent. This demands that either the equity and access
program should be revitalized or a separate program targeting Dalits and Muslims should be
formulated to ensure their improved access to and use of available maternal health services.
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
51
A N N E X
C
DI S CU S S I O N S GU ID ES
(S E V E N E N G L I SH -VER S ION S)
52
GENDER EQUALITY AND SOCIAL INCLUSION FOR FOOD – AND NUTRITION-SECURITY IN NEPAL
GENDER EQUALITY AND SOCIAL INCLUSION
FOR FOOD AND NUTRITION SECURITY IN NEPAL
Question Guide: Mothers
I. Introduction
Welcome and thank you for taking time to participate in this discussion today. My name is........ I
am working on behalf of RDN to conduct a study on health, breastfeeding, and complementary
feeding.
II. Ground Rules
We are interested in all of your opinions and feelings. There is no right or wrong answer. We
need your ideas so any criticisms you have will not hurt our feelings. We encourage you to
provide frank comments that will improve our study.
III. Confidentiality
Everything that is said in today is confidential and only be used for this research purpose I will
also take some notes to help us in this task.
IV. Introduction and Warm Up
Before we begin the discussions, I would like to get to know you a little better since I do not
know much about you so, tell me a little about yourself. Tell me a little about your village,
community, culture family/ interests.
Attention to moderator: please self speak in audio the following:
 District
 VDC
 Ward
 Type of study participant
DG Mother’s Guide –
Demographics
Please note down the following information:
Age(approximate age will suffice if exact date not known)
Education (non-literate, primary school, high school, college,
post-graduate, technical training)
Caste/Ethnicity
Age at marriage
Age at birth of first child
Number, age and gender of children
Household occupation
Aspirations, Fears and Motivation
Here the intention is to find out about the aspirations, dreams, fears and motivations of mothers
1. How do you spend your day, what are the activities you do, which one is your favorite
activity and why?
2. What are the most important things in your life? What do you value very much? Why
so? Can we rank here?
3. Can you tell me about your dreams and aspirations?
4. What changes would you have made to your life if you had complete control?
5. What are the things that make you worry?
[Probe: health? Children? Security? Child’s education? Job/work? Money/income]
Healthcare focus
Interviewer: You said previously (if they did) that good health is one of your concerns. Let’s
talk more about that
6. What specific health concern do you worry about? [Probe: priorities of health]
7. You said that health is something that concerns you. Who do you often talk to get
information about health issues? (Probe: Mother/Mother in law/Friends/Neighbors)
8. Do you have other valuable sources of information on health? [technology, radio, TV,
mobile phones - texting]
9. Who do you believe/feel are the most reliable sources for good information on
healthcare issues? Who do you trust most? [probe: Anyone else? is that who you trust]
DG Mother’s Guide –
10. Is there anything you personally can do to solve these health concerns you mentioned?
[Probe:
11. If yes, what have you done?
•
Do you know what motivated you to do that? EXPLORE MORE DETAILS TO
UNDERSTAND STRONG MOTIVATOR
12. Is there anything that you have wanted to do but felt that you couldn’t? Have you
faced any obstacles that have prevented you from taking any action? What are they?
How did you feel about that? Do you think that you should overcome these barriers in
the future? How would you overcome?
Interviewer: Let’s now talk about when you first learned you were pregnant.
Pregnancy
13. Can you remember the advice you received from health worker (HW, FCHV, TH)
regarding what to do when pregnant? [Probe: eating, sleeping, working,
breastfeeding]
14. Can you remember any advice you received from family and friends (Mother in law,
husband, community leader, religious leader)? [Probe: eating, sleeping, working,
breastfeeding]?
15. Were there other sources of information you received when you were pregnant?
[technology, mass media, workplace]
16. Whom do you trust the most for advice? Whose advice do you usually follow?
17. In your community what type of support did you receive when you were pregnant and
shortly after you had the baby? (Why? who, what do they do and how do they
support?) How are they helpful?
Breast Feeding Divide question – first child and multiple births
18. Is this your first child? [If so continue through 18b-21; if multiple births ask 18a.]
18a. Did you exclusively breastfeed your other children? If so, for how long?
DG Mother’s Guide –
18b.First child: Do you plan on exclusively breastfeeding your child? (or are you now
exclusively breastfeeding your child)?
19. Earlier you said the HCW talked about breastfeeding? Do you remember what she
told you? [Probe: 1 hour, exclusive, no food, no water, how often]
20. How do you feel about breastfeeding? [Probe: negatives and positives; what did
breastfeeding mean to you whenever you heard it discussed]
21. Do you have any thoughts on what limitations to exclusive breastfeeding? [Probe:
What are they? Is there something that could be done to make it easier to breastfeed]
Complementary feeding
22. When you talked to your health care worker/mother-in-law (see response above) did
they discuss with you feeding your child healthy foods or complementary/instant
feeding? When you should begin complementary feeding?
23. Were you familiar with instant feeding? Tell me what you know about it: [Probe:
when to start; how to use it; benefits]
24. Who has been the most influential in choosing what foods to feed your child?
25. Whose opinion do you value the most in regard to your child’s health?
26. Do you feel you have the power to make your own decisions? [Probe. About your
health, your child’s, how to care for him/her]
27. What other beliefs influence your decisions about certain foods – diversity of foods?
28. Ask women what foods they think are good for their babies and what foods they think
are bad for their babies–just make two lists. If there is time you could even rank them
from healthiest to unhealthiest.
29. Who in the family would make the decision to use instant complementary foods?
[Probe: husband, mother, her, HCW – is it discussed?]
30. Who would buy the instant complementary food? Husband/Mothers (you)/other
caregivers?
31. Have you seen micronutrient powders or instant foods in the market? Has the HCW
or your family talked about them?
32. Besides you, who looks after your children?
DG Mother’s Guide –
Challenges and Barriers
33. What prevailing feeding practices put the lives of infants and young children at risk?
[Probe: hygiene, water, availability of nutritious/good foods, frequency of feeding,
amount of food, texture of food, variety, active feeding—including food handling?
34. Do you believe you have proper access to health services regarding breastfeeding
instruction and complementary feeding?
35. Do you feel you understand the importance of breastfeeding on your child’s health
and well-being?
Is there anything else you want to tell me?
Thank you for your cooperation
DG Mother’s Guide –
GENDER EQUALITY AND SOCIAL INCLUSION
FOR FOOD AND NUTRITION SECURITY IN NEPAL
Question Guide: mothers-in-law
I. Introduction
Welcome and thank you for taking time to participate in this discussion today. My name is........ I
am working on behalf of RDN to conduct a study on health, breastfeeding, and complementary
foods.
II. Ground Rules We are interested in all of your opinions and feelings. There is no right or wrong answer. We
need your ideas so any criticisms you have will not hurt our feelings. We encourage you to
provide frank comments that will improve our study.
III. Confidentiality
Everything that is said in today is confidential and only be used for this research purpose I will
also take some notes to help us in this task.
IV. Introduction and Warm Up
Before we begin the discussions, I would like to get to know you a little better since I do not
know much about you so, tell me a little about yourself. Tell me a little about your village,
community, culture family/ interests.
Attention to moderator: please self speak in audio the following:
 District
 VDC
 Ward
 Type of study participant
Mothers-­‐in-­‐law Discussion Guide Demographics
Please note down the following information:
Age(approximate age will suffice if exact date not known)
Education (non-literate, primary school, high school, college,
post-graduate, technical training)
Caste/Ethnicity
Age at marriage
Age at birth of first child
Number, age and gender of children
Household occupation
Aspirations, Fears and Motivation
Here the intention is to find out about the aspirations, dreams, fears and motivations of fathers
1. How do you spend your day, what are the activities you do, which one is your favorite
activity and why?
2. What are the most important things in your life? What do you value very much? Why
so? Can we rank here?
3. Can you tell me about your dreams and aspirations?
4. What changes would you have made to your life if you had complete control?
5. What are the things that make you worry?
[Probe: health? Children? Grandchildren? Security? Education? Job/work?
Money/income]
6. You mentioned how important your children and grandchildren and their well-being
are to you. What do you want for your children? For your grandchildren? What are
your dreams and aspirations for them? What challenges or obstacles stand in the way
to achieve/realize these aspirations?
Healthcare focus
Interviewer: You said previously (if they did) that good health is one of your concerns. Let’s
talk more about that
7. What specific health concern do you worry about? [Probe: priorities of health]
Mothers-­‐in-­‐law Discussion Guide 8. Earlier you said that health is something that concerns you. Who do you often talk to
get information about health issues? (Probe: Daughter-in-law, Son, Friends)
9. Do you have other valuable sources where you receive information on health?
[technology, radio, TV, internet, mobile phones - texting]
10. Who do you believe/feel are the most reliable sources for good information on
healthcare issues? [probe: Anyone else? is that who you trust?]
11. Is there anything you personally can do to solve these health concerns you mentioned?
[Probe:
12. Have you done that? [Probe:
•
Do you know what motivated you to do that? EXPLORE MORE DETAILS TO
UNDERSTAND STRONG MOTIVATOR
13. Is there anything that you have wanted to do but felt that you couldn’t? Have you
faced any obstacles that have prevented you from taking any action? What are they?
How did you feel about that? Do you think that you should overcome these barriers in
the future? How would you overcome?
Interviewer: Let’s now talk about when your daughter-in-law found out that she was pregnant.
Pregnancy
14. Did you go with her to the clinic? If so, can you remember the advice she received
from health worker (HW, FCHV, TH) in regards to what to do when pregnant?
[Probe: eating, sleeping, working, breastfeeding]
15. Can you remember any advice you or she received from others such as family and
friends (relatives, friends, community leader, religious leader)? [Probe: eating,
sleeping, working, breastfeeding]?
16. Were there other sources of information where you or she received when you were
pregnant? [technology, mass media, workplace]
17. Whom do you trust the most for advice? Whose advice do you usually follow? Whose
advice is your daughter-in-law most likely to follow? (If respondent says mine/my
advice: other than your advice whose advice is she most likely to follow?)
Mothers-­‐in-­‐law Discussion Guide 18. In your community what type of support did you or your daughter-in-law receive
when she was pregnant and shortly after the baby was born? (Why? who, what do
they do and how do they support?) How are they helpful?
Breast Feeding
19. Is this her first child?
20. Did you exclusively breastfeed your children? Do you remember for how long –
months or days?
21. Have you talked to your daughter-in-law about her pregnancy?
21. Can you tell me what advice you have told her? [Probe: breastfeeding? Working?
Exercise? Eating? if breastfeeding, Probe for specifics - when do you start? For how long?
Understanding of exclusive]
22. Do you have an opinion about breastfeeding? [Probe: positive benefits; negative]
23. Do you have any thoughts on what limitations to exclusive breastfeeding? [Probe:
What are they? Is there something that could be done to make it easier to breastfeed]
24. When people talk about breastfeeding how would you define it? [Probe: exclusively
(explain that term), breastfeeding with regular food]
Complementary feeding
25. Did you use instant/complementary feeding for your children? Tell me about your
experience [Probe: when did you start, what kind of foods, did you prepare it or buy it, how long
did you use it]
26. Who has been the most influential in choosing what foods to feed your grandchild?
27. What role do you have in feeding your grandchild? What role does your son have?
28. Do you feel that you have the power to make your own decisions [Probe. About your
health, your children, how to care for him or her]
29. Do you feel that your daughter-in-law has the power to make her own decisions?
(Same probe as above)
30. What other beliefs influence your decisions about certain foods – diversity of foods?
Mothers-­‐in-­‐law Discussion Guide 31. What foods do you think are good for your baby and what foods do you think are bad
for your baby –just make two (2) lists. If there is time you could even rank them from healthiest
to unhealthiest. [this is to determine if there are food selection by ethnic groups as well as
general practices]
a. Do you ever feed the baby instant complementary foods?
32. Who in the family would make the decision to use instant complementary foods?
[Probe: husband, mother, her, HCW – is it discussed?]
33. Who would buy the instant complementary food? Husband/Mothers/you/other
caregivers?
34. Have you seen micronutrient powders or instant foods in the market? Has the HCW
or your family talked about them?
35. Besides your wife, who looks after your children?
b. How often do you personally look after the children?
c. When is that specifically?
Challenges and Barriers
36. What prevailing feeding practices put the lives of infants and young children at risk?
[Probe: hygiene, water, availability of nutritious/good foods, frequency of feeding, amount of
food, texture of food, variety, active feeding—including food handling?
37. Do you believe you have proper access to health services regarding breastfeeding
instruction and complementary feeding?
38. Do you feel you understand the value of breastfeeding on your child’s health and
well-being?
Is there anything else you want to tell me?
Thank you for your kind cooperation
Mothers-­‐in-­‐law Discussion Guide GENDER EQUALITY AND SOCIAL INCLUSION
FOR FOOD AND NUTRITION SECURITY IN NEPAL
Question Guide: Fathers
I. Introduction
Welcome and thank you for taking time to participate in this discussion today. My name is........ I
am working on behalf of RDN to conduct a study on health, breastfeeding, and complementary
foods.
II. Ground Rules We are interested in all of your opinions and feelings. There is no right or wrong answer. We
need your ideas so any criticisms you have will not hurt our feelings. We encourage you to
provide frank comments that will improve our study.
III. Confidentiality
Everything that is said in today is confidential and only be used for this research purpose I will
also take some notes to help us in this task.
IV. Introduction and Warm Up
Before we begin the discussions, I would like to get to know you a little better since I do not
know much about you so, tell me a little about yourself. Tell me a little about your village,
community, culture family/ interests.
Attention to moderator: please self speak in audio the following:
 District
 VDC
 Ward
 Type of study participant
Father’s Guide Demographics
Please note down the following information:
Age(approximate age will suffice if exact date not known)
Education (non-literate, primary school, high school, college,
post-graduate, technical training)
Caste/Ethnicity
Age at marriage
Age at birth of first child
Number, age and gender of children
Household occupation
Aspirations, Fears and Motivation
Here the intention is to find out about the aspirations, dreams, fears and motivations of fathers
1. How do you spend your day, what are the activities you do, which one is your favorite
activity and why?
2. What are the most important things in your life? What do you value very much? Why
so? Can we rank here?
3. Can you tell me about your dreams and aspirations?
4. What changes would you have made to your life if you had complete control?
5. What are the things that make you worry?
[Probe: health? Children? Security? Child’s education? Job/work? Money/income]
6. You mentioned how important your children and their well-being are to you. What do
you want for your children? What are your dreams and aspirations for them? What
challenges or obstacles stand in the way to achieve/realize these aspirations?
Healthcare focus
Interviewer: You said previously (if they did) that good health is one of your concerns. Let’s
talk more about that
7. What specific health concern do you worry about? [Probe: priorities of health]
8. Earlier you said that health is something that concerns you. Who do you often talk to
get information about health issues? (Probe: Mother/Mother in law/Friends)
Father’s Guide 9. Do you have other valuable sources where you receive information on health?
[technology, radio, TV, internet, mobile phones - texting]
10. Who do you believe/feel are the most reliable sources for good information on
healthcare issues? Who do you trust most? [Probe: Anyone else? is that who you trust]
11. Is there anything you personally can do to solve these health concerns you mentioned?
[Probe]
12. Have you done that? [Probe: How]
•
Do you know what motivated you to do that? EXPLORE MORE DETAILS TO
UNDERSTAND STRONG MOTIVATOR
13. Is there anything that you have wanted to do but felt that you couldn’t? Have you
faced any obstacles that have prevented you from taking any action? What are they?
How did you feel about that? Do you think that you should overcome these barriers in
the future? How would you overcome?
Interviewer: Let’s now talk about when your wife found out that she was pregnant.
Pregnancy
14. Did you go with her to the clinic? If so, can you remember the advice you or she
received from health worker (HW, FCHV, TH) in regards to what to do when
pregnant? [Probe: eating, sleeping, working, breastfeeding]
15. Can you remember any advice you or she received from family and friends (Mother in
law, community leader, religious leader)? [Probe: eating, sleeping, working,
breastfeeding]?
16. Were there other sources of information where you or she received when you were
pregnant? [technology, mass media, workplace]
17. Whom do you trust the most for advice? Whose advice do you usually follow? Whose
advice is your wife most likely to follow? (If respondent says mine/my advice: other
than your advice whose advice is she most likely to follow?)
18. In your community what type of support did you or your wife receives when she was
pregnant and shortly after the baby was born? (Why? who, what do they do and how
do they support?) How are they helpful?
Breast Feeding Divide question – first child and multiple births
Father’s Guide 19. Is this your first child? [If so continue through 20b-23; if multiple births ask 20a.]
20a.Did your wife exclusively breastfeed your other children? Do you remember for how
long – months or days?
20b.If this is your first child, who have you talked to about your wife’s pregnancy?
[Probe: HCW, mothers-in-law, friend]
21. Can you tell me what you remember they told you? [Probe: breastfeeding? Working?
Exercise? Eating? if breastfeeding, when do you start? For how long? Understanding of
exclusive]
22. Do you have an opinion about breastfeeding? [Probe: positives, negatives]
23. Do you have any thoughts on what limitations to exclusive breastfeeding? [Probe:
What are they? Is there something that could be done to make it easier to breastfeed]
Complementary feeding
24.Whenyou/your wife talked to your health care worker/mother-in-law (see response
above) did they discuss with you feeding your child healthy foods or complementary/instant
feeding?
25. Were you familiar with instant complementary feeding? Tell me what you know
about it: [Probe: when to start; what foods to start with; for how long; water]
26. Who has been the most influential in choosing what foods to feed your child?
27. What role do you have in feeding your child? What role does your wife have? Do you
feel you have the power to make your own decisions? [Probe. About your health, your child’s,
how to care for him/her]
28. Do you feel that your wife has the power to make her own decisions? (Same probe as
above)
29. What other beliefs influence your decisions about certain foods – diversity of foods?
30. What foods do you think are good for your baby and what foods do you think are bad
for your baby–just make 2 lists. If there is time you could even rank them from healthiest to
unhealthiest.
Father’s Guide a. Do you ever feed the baby instant complementary foods?
31. Who in the family would make the decision to use instant complementary foods?
[Probe: husband, mother, her, HCW – is it discussed?]
32. Who would buy the instant complementary food? Husband/Mothers(you)/other
caregivers?
33. Have you seen micronutrient powders or instant foods in the market? Has the HCW
or your family talked about them?
34. Besides your wife, who looks after your children?
b. How often do you personally look after the children?
c. When is that specifically?
Challenges and Barriers
35. What prevailing feeding practices put the lives of infants and young children at risk?
[Probe: hygiene, water, availability of nutritious/good foods, frequency of feeding, amount of
food, texture of food, variety, active feeding—including food handling]
36. Do you believe you have proper access to health services regarding breastfeeding
instruction and complementary feeding?
37. Do you feel you understand the value of breastfeeding on your child’s health and
well-being?
Is there anything else you want to tell me?
Thank you for your kind cooperation.
Father’s Guide GENDER EQUALITY AND SOCIAL INCLUSION
FOR FOOD AND NUTRITION SECURITY IN NEPAL
Question Guide: HW/FCHV/Traditional Healer
I. Introduction
Welcome and thank you for taking time to participate in this discussion today. My name is........ I
am working on behalf of RDN to study on Gender Equality and Social Inclusion related to
breastfeeding and complementary feeding.
II. Ground Rules
We are interested in all of your opinions and feelings. There is no right or wrong answer. We
need your ideas, so any criticisms you have will not hurt our feelings. We encourage you to
provide frank comments that will improve our study.
III. Confidentiality
Everything that is said today is confidential and will only be used for this research purpose. I will
also take some notes to help us in this task.
Attention to moderator: please self speak in audio the following:
 District
 VDC
 Ward
 Type of study participant
 Name of Respondent
 Date of interview
Respondent Background
Please note down the following information:
Sex
Age
HCW DG Caste/Ethnic group
Education
Years in Service
Position
Duration at the health facility
Mobile phone number
Pregnancy
1. Can you share with me about the kind of work you are involved in related to breast
feeding and infant and young child feeding? What problems do you face in your work?
How do you overcome them?
2. Do you get training or support for your work? From what organization? How helpful has
the training been? Probe: any training specific to breast feeding or IYCF?
3. [Role Play] What would you tell me if I were coming to the clinic and am pregnant for
the first time: [Look for breastfeeding instructions and if mentioned specific instructions
– 1 hour, exclusive, no water, no other foods]
4. You did (or didn’t) mentioned breastfeeding. When do you go into more detail with a
pregnant women and her family about breastfeeding and instant foods?
5. What would you tell a woman who has already had a child? [Role Play again for woman
with multiple births]
6. When women talk about breastfeeding what do you think they mean by breastfeeding?
[Probe: is it only exclusive breastfeeding or intermittent with other foods or only for a
few days]
7. What do you hear from women are the positives related to breastfeeding [Probe: healthy
child, grows big, cultural norm]: what are the negatives of breastfeeding that you hear
from mothers (and family members) [Probe: timely, hard to do, too many other demands,
makes me unattractive]
8. Do you believe that pregnant women practice good nutrition behavior in your
community?
9. If yes, how is it different from other women (that is, women who are not pregnant)?
Resting, food, check ups, etc
10. If no, what are the constraints? [Probe]
Breastfeeding
11. What would help mother’s better practice exclusive breastfeeding? What barriers do they
face? How do they overcome them? [Probe]
12. What are the existing breastfeeding practices in your community?
13. What about child being breastfed within an hour of birth? What about Colostrum?
14. If not – what are the constraints
15. What about exclusive breast feeding to children till 6 months?
16. If not – why do you think so? Probe: social, cultural barriers
17. Why do you think breastfeeding is so important? [Probe]
HCW DG Complementary food
18. Can you elaborate a little on what kind of counseling you give to mothers about feeding
complementary food for children? When do you start discussing complementary foods?
19. Can you tell me about the practices in the community regarding complementary food for
children? What age do they typically start on instant feeding? What is the most common
complementary food for children? How is it prepared?
20. What motivated mothers to practice healthy IYCF behaviors?
21. If no, what are the constraints for these mothers to practice healthy IYCF behaviors?
22. Do you have access to micronutrient powders in the clinic? If so, do you distribute them
to mothers at the appropriate time? If not, do you recommend them to an NGO or
vendor?
Health Seeking Behaviors
23. What are most common health problems you see in children in your community? (Rank
the health problem in order of prevalence in the community)
24. What is the perception of the community on child’s good health? Is it a priority?
25. If not the priority – why do you think so? Any constraints? What would motivate them?
26. How do you handle misattribution of nutrition related problems among children to being
stricken by external forces (sato gayeko) or being complainer (runche)?
27. What is the counselling you provide to mothers with infants or children that are not
eating?
28. What do you think prevents women from accessing health and nutrition services?
29. Do you feel that women (mothers) have the power to make their own decisions? [Probe.
About health, about their children, about how to care for their children, about food
selection for their children]. If so, how do they see it? If not, how do they see it.
Is there anything else you would like to add?
Thank you for kind cooperation
HCW DG GENDER EQUALITY AND SOCIAL INCLUSION
FOR FOOD AND NUTRITION SECURITY IN NEPAL
Question Guide: Influentials: Community and Business Leaders, Educators, Stakeholders
I. Introduction
Welcome and thank you for taking time to participate in this discussion today. My name is........ I
am working on behalf of RDN to study on gender equality and social inclusion for health and
nutrition specifically breastfeeding and complementary foods.
II. Ground Rules
We are interested in your opinions and feelings. There is no right or wrong answers. We need
your ideas, so any criticisms you have will not hurt our feelings. We encourage you to provide
frank comments that will improve our study.
III. Confidentiality
Everything that is said in today is confidential and only be used for this research purpose I will
also take some notes to help us in this task.
Attention to moderator: please self speak in audio the following:
 District
 VDC
 Ward
 Name of Participant
 Date of interview
Demographic
Please note down the following information:
Sex
Age
Caste/Ethnic group
Education
Name of organization/society
Position
DG Community leaders & stakeholders
Duration with the organization
Mobile phone number
Fears and Concerns
1. What are the key concerns that you have about your community? (Things could be
Livelihood, food security, Health, corruption, law and order, child education,
gender/caste ethnic group discrimination)
2. Could you prioritize them – 1 thru 5?
3. Why and how do they affect you and your community? Probe reason and source for each
concern.
4. What can be done to overcome these concerns? What barriers prevent overcoming them?
You did (or didn’t) mentioned gender-issues or social inclusion for all populations.
5. Do you see gender as having an effect on these community issues – either directly or
indirectly?
6. Are there gender-related restraints that limit a woman’s health and the health of her
child? Including health services and decisions-related to adequately caring for her child?
[Probe: traditional beliefs, cultural or social norms, dynamics in the household, dynamics
in the community]
7. What would you recommend as ways to reduce these barriers?
8. Who are the main people that influence or give advice to women? Who are the main
people that influence or give advice to women during pregnancy and breastfeeding?
(Mother in law, husband, FCHVs, Health Worker, traditional healers and religious
leaders, employers, friends, community leaders) Could you put them in order of
influence from the most influential to the least influential?
9. What are the support services available for women during pregnancy and breastfeeding
period other than health clinics (Why? who, what do they do and how do they support?)
How are they helpful?
10. From your perspective, what motivates mothers to practice health behaviours such as
breastfeeding and complementary feedings related to their children especially newborn
and infants?
11. What are the constraints for these mothers to practice healthy IYCF behaviours? [Probe:
sources of food, access to food, knowledge about food, traditional/cultural practices]
DG Community leaders & stakeholders
12. When people in general discuss or refer to breastfeeding what do you think they mean?
[Probe: anything and everything related to breastfeeding, combined with complementary
feeding]
Constraints and supports
13. What is the overall situation of gender dynamics within a household in your community?
Does it vary by cast and ethnic group?
14. Do you believe that women have the power to make their own decisions? [Probe. About
their own health. Health of their children. How to care for their child. Choices of
breastfeeding and complementary feeding] Does it vary by cast and ethnic group?
Influential and trusted sources
15. Who are the most trusted sources of information regarding nutrition and health matters in
this community?
Media Habits
16. Do you have access to TV/Radio/cell phone/ newspaper/magazines/Internet? How often
do you watch/ listen/read/ surf Internet and for how long?
17. How do you receive information – news, attitude of your community, general
communication with family, friends and colleagues?
18. [If said they use the internet or social media] How often do you use internet sites? How
often do you text?
19. Do you have a cell phone? If yes, do you have a smart phone? Does any member in your
household have a cell phone? Is it a smart phone? Aside from making phone calls, what
else do you commonly use your phone to do? What other functions does your phone have
that you don't use on a regular basis?
Thank you for your kind cooperation
DG Community leaders & stakeholders
GENDER EQUALITY AND SOCIAL INCLUSION
FOR FOOD AND NUTRITION SECURITY IN NEPAL
Question Guide: Pharmacist (shopkeepers, vendors)
I. Introduction
Welcome and thank you for taking time to participate in this discussion today. My name
is........ I am working on behalf of RDN to conduct a study on gender-issues related to
breastfeeding and complementary feeding.
II. Ground Rules
We are interested in your opinions and feelings. There is no right or wrong answer. We
need your ideas, so any criticisms you have will not hurt our feelings. We encourage you
to provide frank comments that will improve our study.
III. Confidentiality
Everything that is said in today is confidential and only be used for this research purpose.
I will also take some notes to help us in this task.
Attention to moderator: please self speak in audio the following:
 District
 VDC
 Ward
 Name of pharmacy
 Name of Respondent
 Date of interview
Background information
Please note down the following information:
Sex
Age
DG Pharmacists & Vendors
Caste/Ethnic group
Education
Years in service as pharmacist
Location of shop (in market, stand alone)
Position
Duration at that pharmacy
Mobile phone number
Health Seeking Behaviour
1. What kinds of inquiries do you receive from your customers about childhood
illnesses? (Rank them)
2. Do you receive questions about complementary foods?
3. Who usually ask about the complementary foods? [Husbands, wives, mothers-inlaw, HCW?]
4. Do you get training or support for your work? If not specifically mentioned,
PROBE: have you received any training regarding breastfeeding or IYCF? If so,
how helpful were these trainings? Who conducted the training?
Constraints and measures
5. What do you see as prevailing feeding practices that put infants and young
children at risk?
6. What problems do women face accessing health and nutrition services?
7. Which of these are related to gender norm issues?
8. I see some products in your pharmacy. What prevents your customers from
accessing the products you carry? [cultural norms, costs, consumer does not know
about them]
9. What are you views about nutrition for children? What are views of mothers and
community on under nutrition?
10. What do you think would help the community better understand the value of
breastfeeding and complementary foods? [Probe: training, communication,
promotion]
Observational research for Instant readymade complementary food in shops and
markets and questions for value chain
DG Pharmacists & Vendors
•
Personal observation in the shop/market /pharmacies (take pictures of each of the
following items): All
o
Observe if product is on the shelf
o
Note price [Price per service or price per month in analysis]
o
Observe where product is placed in the shop – is it promptly displayed or
hidden
o
Observe if there are Point of Purchase (POP) materials on display in the
shop promoting the complementary foods? Low or high literacy?
Memorable? Eye-catching? Understandable?
o
Product packaging – is it colorful? Memorable? Eye-catching? Lowliteracy or high-literacy? Instructions on how to use and prepare ICYF?
•
Discussion with shop owner (take pictures of vendor and customers in the shop or
market)
o
Ask shop owner if product sells – who buys it (man, woman, mothers-inlaw; socio-economic, caste ethnic group), how often do they purchase it,
what do they pay/what is the price; do they come in and ask for it?
o
Has the owner had any academic detailing about the products? Someone
to explain its value or worth?
o
Product – packaging? Colorful? Attractive? Easy to use? Instructions or
directions (low literacy or high literacy)
o
What is the average time for the product on the shelf?
o
Who is the distributor and/or manufacturer?
o
Does the shop owner see this as a money return product (do they make a
profit)
•
Content analysis
o
Observe the content of any promotion related to IYCF – ads, print
materials, POP, packaging, newspapers
Thank you for your kind cooperation
DG Pharmacists & Vendors
GENDER EQUALITY AND SOCIAL INCLUSION
FOR FOOD AND NUTRITION SECURITY IN NEPAL
Question Guide: Media (Reporters, Journalists)
I. Introduction
Welcome and thank you for taking time to participate in this discussion today. My name is........ I
am working on behalf of RDN to study on gender equality and social inclusion for health
specifically breastfeeding and infant and young child feeding.
II. Ground Rules
We are interested in all of your opinions and feelings. There is no right or wrong answer. We
need your ideas, so any criticisms you have will not hurt our feelings. We encourage you to
provide frank comments that will improve our study.
III. Confidentiality
Everything that is said in today is confidential and only be used for this research purpose I will
also take some notes to help us in this task.
Attention to moderator: please self speak in audio the following:
 District
 VDC
 Ward
 Type of Media
 Your job (reporter/journalist)
 Specialty
 Years as reporter/journalist
 Name
 Designation
 Date of interview
Media DG 1. Who is/are your primary audience(s)? Men? Women? General Public? Officials?
Business and Government Leaders?
2. What stories are of general interest to your audiences? – news, features, celebrity
news and popular culture, health? To your editors? To you?
3. How engaged is your audience in gender-related issues? Nutrition and food security
issues? Mothering and parenting?
4. How do your audiences between 18-35 get their information....are they reading
newspapers? Or watching TV/listening to radio? Or using social media (Twitter,
Facebook, Yahoo – web-based communication tools, texting)?
5. How do you get your information? Probe: newspapers, broadcast, internet, social
media, individuals/influentials?
6. Do you have a social media account for your writing?
7. Who do you see as credible sources of information?
8. In order of priority what are the top five social issues within the community?
9. Is there attention or focus in the media on gender issues? good nutrition or food
security practices? Breastfeeding or IYCF?
10. Specific to breastfeeding, when people talk about breastfeeding what do you think
they are referring to? [Probe for specifics]
11. What do you believe are the positives of breastfeeding? [Probe: health to the child,
health to the mother, child grows big and strong, cultural/social practice, it is done];
what are the negatives of breastfeeding? [Probe: takes too much time. Hard to do.
Child is always hungry. Makes me unattractive.]
12. In order of priority with #1 being the main concern what are the key concerns and
barriers of gender behaviour in your district? Does it vary with cast and ethnic group?
13. Do you feel that women (mothers) have the power to make their own decisions?
[Probe. About health, about their children, about how to care for the children]
14. What is the overall situation of gender dynamics within a household in your district?
Does it vary with cast and ethnic group?
15. Is there attention or focus in the media on gender issues and equality? In households
or in work place? Is it encouraged or discouraged?
Media DG 16. Are you familiar with Infant and Young Child Feeding? Have you reported on it? Or
has your paper/tv or radio station covered it?
Thank you for your kind cooperation
Media DG