Value Chains for Nutrition in Rural India: investigating barriers among women
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A4NH and IFPRI Gender Task Force seminar on “Value Chains for Nutrition in Rural India: Investigating barriers to fruit and vegetable consumption among women of reproductive age” presented by Sarah Kehoe, Senior Research Fellow Medical Research Council Lifecourse Epidemiology Unit (MRC LEU), University of Southampton, UK
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Value Chains for Nutrition in Rural India: investigating barriers among women
- 1. Value Chains for Nutrition in Rural India Investigating barriers to fruit and vegetable consumption among women of reproductive age Sarah Kehoe sk@mrc.soton.ac.uk
- 2. Overview • Introduction to the work at MRC • Public health challenges in India • Description of previous longitudinal research in India that led to LANSA-funded ‘Value chains for nutrition’ study • Value chains for nutrition study • Future plans 2
- 3. MRC Lifecourse Epidemiology Unit 3 http://www.mrc.soton.ac.uk
- 4. MRC Lifecourse Epidemiology Unit 4 http://www.mrc.soton.ac.uk
- 5. 5
- 6. India UK Population 1.22 bn 63.7m % Living in rural areas 70 20 Population density per km2 373 255 Gross National Income per capita (US$/ year) 1,410 37,780 Human Development Index Score* 0.547 0.863 Human Development Index Ranking * 134/187 28/187 Gender Inequality Index Ranking* 129/146 34/146 6 *United Nations Development Programme data
- 7. Indian Population between 1950 and 2100 by age groups and sex (absolute numbers in millions) 7
- 8. 2015 Global Hunger Index South, East and SE Asia 8Source: International Food Policy Research Institute. http://ghi.ifpri.org/ Country Proportion of undernourished in population (%) Prevalence of wasting in children <5 years (%) Prevalence of stunting in children <5 years (%) Under five mortality rate (%) Score Timor-Leste 26.9 18.9 57.7 5.5 40.7 Afghanistan 26.8 9.5 40.9 9.7 35.4 Pakistan 22 10.5 45 8.6 33.9 India 15.2 15 38.8 5.3 29 North Korea 41.6 4 27.9 2.7 28.8 Lao PDR 18.5 6.4 43.8 7.1 28.5 Bangladesh 16.4 14.3 36.1 4.1 27.3 Sri Lanka 22 21.4 14.7 1 25.5 Myanmar 14.2 7.9 35.1 5.1 23.5 Cambodia 14.2 9.6 32.4 3.8 22.6 Nepal 7.8 11.3 37.4 4 22.2 Indonesia 7.6 13.5 36.4 2.9 22.1 Philippines 13.5 7.9 30.3 3 20.1 Mongolia 20.5 1 10.8 3.2 14.7 Vietnam 11 5.7 19.4 2.4 14.7 Thailand 7.4 6.7 16.3 1.3 11.9 Malaysia 2* 10.7* 11.2* 0.9 10.3 Fiji 4.5* 6.6* 3.7* 2.4 8.7 China 9.3 2.3 9.4 1.3 8.6
- 9. Mapping of BMI of Indian women aged 15-49 by state (2005-6) 9
- 10. Age standardised prevalence of raised fasting blood glucose by country in 2008 10Source: WHO Global Health Observatory. Raised blood glucose is defined as ≥7.0mmol/L or being on medication for raised blood glucose ages ≥25years
- 11. Global burden of low birth weight and diabetes 11 Type 2 Diabetes LBW
- 12. Approximately 2 billion people globally are micronutrient deficient with women of reproductive age disproportionately affected. 12 (Black et al, Lancet 2008;371:243-60 & Ramakrishnan, Nutr Rev 2002;60:S46-S52)
- 13. Pune Maternal Nutrition Study • Observational data from villages outside Pune, India showed that intakes of green leafy vegetables, fruit and milk were positively associated with birth size. 13 2.5 2.6 2.7 2.8 Never <1/wk 1/wk >3/wk Green leafy vegetables intake @ 28 wks p<0.001 Source: Rao. J Nutr 2001;131:1217-1224 Birth weight (kg)
- 14. Mumbai Maternal Nutrition Project • Randomised controlled trial of a food- based supplement. • Primary outcomes: birth size and infant mortality. • Participants were married women of reproductive age, living in Mumbai slums and intending to have children. • The supplement was consumed daily for at least 3 months pre-conceptionally and throughout pregnancy. 14
- 15. 15 Birthweight(g) ALL WOMEN CONTROL TREATMENT Mother’s pre-pregnant BMI (kg/m2) <18.6 18.6-21.8 >21.8 + 48g - 8g + 79g + 113g Mean and 95% confidence intervals p value for interaction: p=0.001 2350 2400 2450 2500 2550 2600 2650 2700 2750 2800 2850 0 Potdar R et al. AJCN 2014; 100: 1257-68 Sahariah S et al. J Nutr 2016 (in press) Gestational diabetes: Treatment: 7.3% Control: 12.4% OR (95%CI) 0.56 (0.36, 0.86) Mumbai Maternal Nutrition Project -Results
- 16. Fruit and Vegetable Intakes 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 UK population India slum India rural Medianportionsoffruit andvegetables/day Source: National Diet and Nutrition Survey, UK; National Family Health Survey-3, India
- 17. To summarise… • Intakes of fruit and vegetables are low in rural India. • Increasing intakes may improve fetal growth and development thereby reducing risk of mortality in the short term and preventing chronic disease in the longer term. 17
- 18. Why are fruit and vegetable intakes low in rural India? What are the modifiable constraints to fruit and vegetable intakes? 18
- 19. Determinants of Dietary Diversity “Variety of foods across and within food groups capable of ensuring adequate intakes of essential nutrients” (FAO/WHO 1996). Diet diversity in rural East India was poor among: • Low educated • Low socio-economic status • Families with female head of households • Families with poor purchasing power Parappurathu et al, 2015. Food Security, 7(5); 1031-1042 19
- 20. Identifying nutrition-sensitive interventions to improve maternal diet quality in rural Indian settings using value chain analysis
- 21. Core Objectives 1. To undertake exploratory qualitative research to identify constraints and facilitators to consumption of fruit and vegetables in rural Maharashtra. 2. To map the value chains for selected exemplar foods. 3. To provide policy-relevant output regarding the incorporation of nutritional priorities into value chain activities.
- 22. Core Objectives 1. To undertake exploratory qualitative research to identify constraints and facilitators to consumption of fruit and vegetables in Maharashtra. 2. To map the value chains for selected exemplar foods. 3. To provide policy-relevant output regarding the incorporation of nutritional priorities into value chain activities.
- 23. Study Setting & Team
- 25. Approach • Qualitative • Exploratory • Hypothesis generating • Researcher aims to have no pre-conceptions when collecting data
- 26. Design And Methods • Workshops with Stakeholders in Mumbai and Wardha 1) Research gaps; linking fruit and vegetable value chains with nutrition. 2) Obtain perspectives of stakeholders on problems and potential solutions. 3) Identify exemplar fruit and vegetable value chains to be studied in detail. • Focus group discussions with women consumers. • In depth interviews with value chain actors (farmers, wholesalers and vendors). • Second set of stakeholder workshops to discuss findings and propose interventions.
- 27. Stakeholder Workshops • Mumbai Workshop Attendees Maharashtra State Rural Livelihood Mission Mahila Arthik Vikas Mahamandal (MAVIM) Indira Gandhi Institute of Development Research National Institute of Nutrition • Constraints to fruit and vegetable intakes Time demands Gender Inequality Land use / cash crops Poverty Political will Difficulty linking agriculture with nutrition and health at the State level Importance of understanding the problems from consumer’s point of view
- 28. Stakeholder Workshops • Wardha Workshop Attendees Maharashtra State Rural Livelihood Mission Zilla Parishad Representatives of Farmers’ Unions, Consumers, Farmers, Vendors • Exemplar fruit and vegetable value chains to be studied using in depth interviews: Mango Guava Spinach Bhindi
- 29. Focus Group Discussions • Women recruited by ‘key persons’ in the villages. • 8-10 women per group. Grouped by caste, age and land ownership. • Audio-tape recorded, transcribed and translated to English.
- 30. Focus Group Discussions • 8 FGD conducted. • Total of 82 women. • Inductive thematic analysis was used to identify emerging themes. • Data collection stopped when no new themes emerged.
- 31. Identifying Key Themes • Preliminary Findings Household Dynamics Workload Personal Factors Time Pressures Practical Factors Social and Cultural Norms Cost
- 32. Household Dynamics “Women do not get to eat proper meals the way they are supposed to. Men would get proper meal (laugh)” “There is big family.. hence there is no question to take any decision. Whatever [vegetables] we get we prepare that”
- 33. Workload “I get tired in the evenings. So do not have meal, somehow gulp a morsel or two and go to bed”. “We have to fetch water, wash utensils, get flour from the mill, go to field. That is what woman has to do. After that only she gets to eat”
- 34. Personal Factors “Fenugreek and spinach are the only two green leafy vegetables I like ” “My daughters are having (fruits), this is more than enough. Not bothered about myself. I overcome my craving”
- 35. Time Pressures “I don’t like to keep pending work. I am ok if do not get food but I am happy if I finish all work within time. “I don’t have full meal in the morning because I have to rush to farm”
- 36. Practical Factors “Whenever we go to Wardha we get it [fruit]. Every day we cannot have. We go Wardha once in one or two months” “Those who have place may prepare kitchen garden at home.. can cultivate green vegetables. Those who do not have place can not cultivate. They do not have any other option than buying.”
- 37. Social and Cultural Norms “Papaya is hot. [This] means in pregnancy if you have it then there is more chances of miscarriage. My grandmother said” “How can he help me? If he helps me in household chore then in village, everybody gossip about him or say bad things”
- 38. Cost “When there is the inflation that time, they mostly invest their money in the farm and in the house; hence they create thrifty condition in home” “During summer, the vegetable which is 5 rupees per 250 grams becomes 20-25 rupees per 250 grams”
- 39. Next steps • Analysing in-depth interviews with actors focusing on exemplar food value chains. • Hold further stakeholder workshops to discuss our findings and develop ideas for interventions.
- 40. Challenges • Developing relationships with State Agriculture and Marketing departments. • Issue of context and how to make the outputs of the project relevant to different settings.
- 41. Acknowledgements • Study participants • MSSRF Wardha gender team and administration staff • Dr Rengalakshmi and colleagues, MSSRF Chennai • Aulo Gelli, IFPRI • Centre for Study of Social Change • Wendy Lawrence, Kumaran Kalyanaraman and Ilse Bloom at MRC LEU
- 42. Thank you for your attention! Questions? sk@mrc.soton.ac.uk
Hinweis der Redaktion
- I’m going to talk about a value chain analysis project which is aiming to identify nutrition sensitive interventions to improve women’s diet quality in rural Maharashtra with a focus on fruit and vegetables. I am based at the University of Southampton MRC Lifecourse Epidemiology Unit. The lead organisation in this research is the Centre for Study of Social Change, a small NGO in Mumbai directed by Dr Ramesh Potdar. CSSC have been doing research into maternal and child nutrition in collaboration with the University of Southampton for the past 15 years. The other partners in this project are MSSRF and IFPRI who are well known to this audience.
- 29 states
- Birth weight is a crude but frequently used proxy for intra-uterine growth because it is relatively easy to measure. Low birth weight is defined as less than 2.5kilograms and as you can see from this cartoon in which the size of the country represents the incidence of low birth weight it is a major public health problem in India. You can also see that India has a high burden of type 2 diabetes and the WHO predicts that 80 million adults in India will be affected by the year 2030. Given the link between poor early development and risk of diabetes, we were interested in studying whether improving fetal growth through better quality maternal diets can reduce the risk of developing the disease in India.
- The reason we asked this question is that micronutrient deficiencies are highly prevalent globally and disproportionately affect young women. This is detrimental to the women themselves and also to the next generation. Women who are undernourished tend to have babies with intra-uterine growth retardation who are less likely to achieve their genetic potential in terms of growth and development. In adulthood they are likely to give birth to small babies themselves and continue the cycle shown here.
- Similar findings for fruit and milk
- GDM and birth weight
- Quantitative surveys have shown that diversity of diet was affected by education, economic status, having a female as head of household and where purchasing power was poor. We wanted to do some qualitative work to understand this from the perspective of the women as consumers so that we could design interventions that would effectively increase intakes.
- CSSC have been doing research into maternal and child nutrition in collaboration with the University of Southampton for the past 15 years. The other partners in this project are MSSRF and IFPRI who are well known to this audience.
- The first of our core objectives was to conduct primary qualitative research to explore constraints and facilitators to fruit and vegetable consumption in rural Maharashtra. Of course these factors are likely to be context specific and so we are also planning to develop a conceptual framework linking fruit and vegetable value chains to nutrition that can be applied in different settings. This aspect of the work is being done in conjunction with Aulo Gelli based at IFPRI in Washington. Ultimately we aim to make recommendations for value chain interventions that will increase fruit and vegetable intake in Maharashtra.
- Today I’m going to focus on the first objective and explain what we have done to date in the study and share some preliminary findings.
- The primary data collection activities are based in the villages around the MSSRF Research Centre in Wardha, Eastern Maharashtra. They are being conducted by the study team here Varsha Dhurde, Rashmi Kale and Shilpa Bhaise. We have been fortunate to have intellectual input to the study from Gender researchers Dr Rengalakshmi and Yamuna Menon here at MSSRF. These photographs show the different types of housing in the villages ranging from huts made from sticks and dung to brick built dwellings.
- This slide gives an overview of our research activities. I’ll go into more detail on each in the coming slides. Our first activity was to organise workshops with stakeholders. One in Mumbai in which we explored gaps in research linking fruit and vegetable value chains with nutrition. We also wanted to develop a network of professionals with an interest in such value chains in Maharashtra and obtain their perspectives on nutrition and health problems in the State. A second workshop was held in Wardha to identify exemplar fruit and vegetable value chains which could be studied in detail. We are currently running focus group discussions with women living in the villages around Wardha and we are planning to hold in depth interviews with value chain actors who supply these villages. Once we have completed these activities and looked at the data we plan to hold a further set of stakeholder workshops to discuss our findings and to develop ideas for interventions.
- This slide gives an overview of our research activities. I’ll go into more detail on each in the coming slides. Our first activity was to organise workshops with stakeholders. One in Mumbai in which we explored gaps in research linking fruit and vegetable value chains with nutrition. We also wanted to develop a network of professionals with an interest in such value chains in Maharashtra and obtain their perspectives on nutrition and health problems in the State. A second workshop was held in Wardha to identify exemplar fruit and vegetable value chains which could be studied in detail. We are currently running focus group discussions with women living in the villages around Wardha and we are planning to hold in depth interviews with value chain actors who supply these villages. Once we have completed these activities and looked at the data we plan to hold a further set of stakeholder workshops to discuss our findings and to develop ideas for interventions.
- The first stakeholder workshop was held at CSSC in Mumbai and we welcomed attendees from State Government Agencies concerned with rural livelihoods and women empowerment. Academics from Development and Nutrition sectors also attended. Our discussions identified the following constraints to fruit and vegetable consumption and it was highlighted that gender inequality impacted on the majority of these factors. An important point raised was the necessity to understand health and nutrition problems from the consumer’s viewpoint and that any interventions must be designed with this in mind.
- A second workshop in Wardha was held with more local representatives of government agencies and with farmers union representatives, consumers and other value chain actors. One of the objectives of this workshop was to identify exemplar fruit and vegetables to be studied in detail. The criteria for these exemplars were that they were known by the vast majority of consumers and that there was some variability in consumption within the study population. This would then enable us to study both barriers and facilitators to consumption. I’d like to acknowledge that this model of studying value chains using exemplars was adopted by Emily Morgan a PhD student of Alan Dangour who studied a similar research question in Fiji.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We used the findings from the workshops to develop our focus group discussion guides. We decided to group the women by caste, age and land ownership to make them as comfortable as possible. We have held several pilot discussion groups to establish the best methods for encouraging open discussion. We have found that there is concern among the women for themselves and their children in terms of the lack of diet diversity and low intakes of fruit and vegetables. Cost is an important factor but several other constraints are talked about such as time demands, fasting practices and order of eating within the household. Facilitators that have been mentioned so far are access to kitchen gardens and income generating activities that allow more time for food preparation.
- We are now planning to hold interviews with value chain actors around the extent to which they have choices about products that they grow, market and sell and how they make these decisions. Based on these interviews, the focus group discussions and the workshop findings we will develop the conceptual framework and propose interventions aimed at increasing consumption of fruit and vegetables. We will then hold further workshops to develop ideas for interventions.
- We’ve had some difficulties making contacts with State Agriculture and Marketing departments and would be interested in any ideas on how to engage with this sector. Also we are conscious that the findings of our primary research will be very specific to the locations studied. Any advice on how to ensure that the work is as useful as possible to a wider population would be very helpful.
- We’ve had some difficulties making contacts with State Agriculture and Marketing departments and would be interested in any ideas on how to engage with this sector. Also we are conscious that the findings of our primary research will be very specific to the locations studied. Any advice on how to ensure that the work is as useful as possible to a wider population would be very helpful.
- Thank you for listening