Can social movements improve female nutrition?
Despite economic progress in South Asia, female undernutrition continues to be a significant challenge in the region. This paper focusses on nutrition-focussed social movements initiated by development programming and explores whether such social movements can help improve female nutrition across Low-and-Middle-Income Countries (LMICs) in this region. The first section provides a brief background to the issue and sets the context for analysis. The second section examines the role of gender and social norms in exacerbating female malnourishment in South Asia regions and makes a case for the relevance of social movements in improving female nutrition. The third section highlights the role of development programming in building social movements around gender-sensitive nutrition outcomes. Further, it examines the extent to which such social movements have effectively enhanced female access to nutrition. The paper concludes with an overall assessment of the role of social movements in combatting nutrition-related gender norms, invoking community involvement in female nutrition issues, and reducing female malnourishment – in the South Asian context.
Section 1: Background
Presently, a third of the world’s anaemic women live in South Asia. Further, every one in 10 women is too short, while every one in 5 women is too thin (UNICEF, 2018). A recent population-based study used data between 2000 and 2017 and noted a pooled prevalence of female underweight at 22 percent across seven countries in this region – Bangladesh, Cambodia, India, Myanmar, Nepal, Pakistan, and Timor-Leste (Biswas et al., 2022).
Female under-nutrition impacts several other developmental dimensions for women and girls; it has negative effects on female school achievement, income-generational abilities, and disease survival potential (WHO, 2022). Further, female nutrition outcomes influence future generations– undernourished mothers produce undernourished children, thereby setting off a vicious cycle of undernutrition. In the South Asian context, evidence shows that maternal undernourishment is closely associated with child stunting levels that affect 62 million children in the region (UNICEF, 2018).
At one level, female nutrition is a function of poverty – although here, one may argue that poverty affects all members within a household (Rao, 2020; Siddiqui et al., 2020). However, disparities in male and female nutrition levels within the same household are observed across several studies. For instance, a study in rural Bangladesh found that girls were more severely malnourished than boys (Chowdhury et al., 2000). Similarly, a study performing a rural-urban comparison across two Indian States found nutritional discrimination between male and female children. In this study, 74.3 percent of female children were found to be malnourished, compared to 66.6 percent of male children, across both States (Patel et al., 2013).
In essence, barriers to female nutrition (across households and communities) are largely social – these barriers are deeply rooted in gender norms that deprioritise female nutrition, and limit access for women and girls to household food resources in the South Asian context. In such a setting, combatting female undernutrition is not simply a case of providing/increasing nutritional intake by women and girls, but actively addressing the gender norms/social barriers that prevent women and girls from nutritional intake in the first place. Recognising the social factors contributing to gendered nutrition outcomes, various social movements have been initiated in the South Asian context, to collectively secure women’s access to food and to improve female nutrition outcomes (Fikree & Pasha, 2004). Here, a social movement is defined as ‘collectively acting to promote or resist a change within society’ (Turner & Killian, 1957). In the South Asian context, most of these social movements and community mobilisation efforts have been led/implemented through international development programmes and national policy interventions, which have adopted a holistic approach to tackling female under-nutrition by positioning female nutritional goals as community aspirations. In line with this, the social movements analysed across this paper are those initiated by the development industry, in the form of programmes/ policies and community interventions.
Section 2: Are social movements relevant for addressing female nutrition needs?
To answer if social movements are relevant for improving female nutrition needs, it is important to understand the pivotal role played by socio-cultural norms in influencing women’s nutrition. At the outset, it may be difficult to assess gender discrimination in food access within households, particularly since lower calorific consumption by females can be attributed to their lower energy needs. However, reviewing evidence on gender-specific nutrition levels highlights significant disparities in nutritional access and achievement – particularly across disadvantaged households (Ramachandran, 2007). In South Asia, the gendered nature of malnourishment has its roots in gender bias. In essence, higher malnutrition among women and girls is not simply due to the poverty and deprivation, but to the intrinsically low value attached to female members of households – from a young age. It is a ‘wicked problem’ that is influenced by a range of factors – ranging from income levels to cultural norms and is affected by several stakeholders at the household and community levels (Shafiq et al., 2021). Gender discrimination influences female nutrition through three key pathways, described below.
First, gender bias manifests in the form of ‘son preference’ with female children being denied equal quantities of nutrition, and with food from their share being given to their brothers/other male family members. For instance, a study in Nepal found that the nutrition of girls, but not boys depended on the gender composition of their siblings. In this study, female children were found to be malnourished if they had many older brothers – this meant that little food reached them and only after the prioritised nutritional needs of their brothers were fulfilled (Hatlebakk, 2012). This is also confirmed by the research of Shafiq et al. (2021) in Pakistan, wherein a female child under the age of 5 years was likely to be more malnourished than a male child if there were many children under 5 within that household.
Second, gender norms negatively influence the quality of nutrition provided to women and girls in a household, thereby exacerbating female undernutrition. Notably, a study in Punjab, India noted that though boys and girls across households had similar calorific intake, the nutrient composition varied. While the girls were given more cereals, the boys were provided more milk and fats in addition to their cereal. Differences in the quality of food provided contributed to widening gender disparities in nutritional levels within the same household. Further, with the households being able to afford the more expensive foods (milk, fats), the study noted that gendered differences in food quality were a function of cultural norms that prioritised sons, rather than economic deprivation or poverty (Dasgupta, 1990).
Third, gender norms also influence other harmful religious/socio-cultural practices that deprioritise female nutrition and which are perpetuated at the household and community levels in South Asia. Lentz et al. (2019) analysed the intrahousehold factors identified by South Asian women as detrimental to their own nutrition. In this study, the majority of women confirmed eating least amounts and last (after all the other family members had eaten) within their households, which in turn contributed to their low nutritional levels. In a similar vein, Kabeer (1998) noted that women in Bangladesh imposed nutritional deprivation upon themselves, wherein they constituted the ’residual category’ in household food consumption and ate only what was left after the men and children had eaten. Research from four tribal villages in India also showed that in times of seasonal food shortages, women ate less as a coping strategy – to ensure food availability for the men and children in the households (Ramachandran, 2004).
Analysing these pathways gives way to certain insights. First, female undernutrition is a ‘wicked problem’ influenced by a range of factors (including income, literacy, seasonality, family structure, prevailing religious and cultural norms, societal expectations, existing food systems and market structures) and stakeholders (including family members, community leaders, cultural influencers, policymakers, and programme implementers). Second, gender norms and socio-cultural factors are inextricably linked to female nutrition. Thus, addressing female nutrition needs implies addressing these norms and transforming behaviours/attitudes towards female nutrition for the long term. Finally, given the complex nature of female undernutrition, addressing this challenge requires multistakeholder efforts towards a common goal. Transforming social attitudes and norms positively towards female nutrition will only go as far as stakeholder-buy in for the longer-term lasts.
It is clear therefore that addressing female nutrition sustainably needs interventions that go beyond targeting economic deprivation at the household level (such as food vouchers and cash transfers for vulnerable women and girls). It requires an equal emphasis on social and cultural elements. Given the entrenched gender norms that accord a secondary status to women in South Asian societies, social movements have the potential to fundamentally change gender structures and societal values. Further, social movements elicit buy-ins from stakeholders and can subtly nudge potential supporters to move towards a positive collective goal. In the context of South Asian societies, a social movement can potentially obtain buy-ins from family members, communities, and other development stakeholders towards ensuring female access to adequate and appropriate nutrition. Finally, social norms influence female nutrition in South Asia from one generation to another. Therefore, addressing these norms require a solution that is relatively sustainable. Social movements tend to be relatively long-lasting – they perpetuate themselves through existing institutions (such as civil society organisations, government agencies) and through mass participation.
Thus, the various characteristics of social movements – their socio-cultural focus, stakeholder involvement, and long-lasting nature – make a good theoretical case for them being relevant tools of female nutrition improvement in the South Asian context. It is clear that social movements are relevant for improving female nutrition, but are they effective? The following sections examine evidence on female nutrition-focussed social movements initiated through development programming and through grassroots efforts, and their effectiveness in improving the nutritional outcomes of women and girls in the regions targeted.
Section 3: Are social movements effective in addressing female nutrition needs?
Development practitioners (including international agencies and national governments) adopt various strategies to make female nutrition a social movement – recruiting community leaders as nutrition champions/influencers, social media campaigns, nutrition promotion activities, etc. In recent years, there has also been an increased focus on implementing behaviour change communication (BCC) – particularly through Participatory Learning and Action (PLA) approaches. BCC programs focus on delivering information or reshaping/reinforcing social norms as a key pathway to improving nutrition of women. These programs often consist of awareness and behaviour change promotion in groups facilitated by an external resource person or a trained community member. Further, within a PLA session, individuals within a group engage in a process of identifying shared problems, planning strategies, acting collectively, and assessing impacts. PLA approaches aim to build community capacity to identify problems and act collectively to address them. Such development programming-led social movements aim to transform social norms by aligning the priorities of multiple stakeholders: pregnant/lactating women, their male partners, family members and larger community (Kumar et al., 2018).
Evidence suggests that the social movements emerging from the development industry are largely effective in improving female nutrition outcomes. Results are particularly positive for BCC programmes delivered across various South Asian countries. Notably, in a scoping review of 36 studies reporting on nutritional interventions (across India, Pakistan, Bangladesh, and Nepal), BCC programmes delivered to women’s groups were seen to be most successful for improving maternal nutrition and addressing gender challenges (Kumar et al., 2018). Similarly, BCC sessions conducted for pregnant and lactating women under Myanmar’s Maternal and Child Cash Transfer (MCCT) Programme led to improvements in knowledge of dietary adequacy combatted harmful norms surrounding female nutrition (Mukherjee et al., 2020). Positive results are also seen for BCC programmes that target stakeholders beyond the female beneficiary of nutrition counselling and behaviour change communication services. For instance, a maternal nutrition programme in Bangladesh targets not only pregnant and post-partum women, but also individuals who influence a woman’s nutrition-related decisions (such as family members, community influencers, health care providers) through nutrition counselling, demonstrations, and coaching. This programme was observed to improve dietary diversity and quality for pregnant/lactating women rapidly, thereby highlighting the extent to which such nutritional social movements leverage community buy-in to improve female nutrition outcomes (Ash et al., 2020).
Nutrition-focussed social movements that employ PLA approaches have also seen success in various South Asian contexts. Notably, the Government of Nepal recruited community health volunteers and ‘nutrition mobilisers’ to deliver nutrition counselling to women’s groups through PLA, in combination with food and cash transfers. A randomised controlled trial (RCT) of this programme highlighted that the PLA components (with or without transfers) improved diets for pregnant women – while also enhancing their autonomy in household decisions and their awareness of nutritional knowledge. While the combination of PLA and cash transfers improved dietary diversity, PLA with food transfers improved equity in calorific allocation within households (Harris Fry et al., 2018). Similarly in India, a BCC programme delivered through PLA approaches and including other elements (such as home visits and creches) was observed to improve female dietary diversity for 65-72 percent of mothers, by transforming female attitudes towards nutritional requirements and adequacy. (Gope et al., 2019). Further, in an intervention targeting refugee women on the Thailand-Myanmar border, PLA approaches have contributed to improved dietary diversity among the targeted female beneficiaries (Stevens et al., 2018).
PLA approaches have also proven to be successful in promoting female nutrition at the community level in some contexts. For instance, India’s flagship nutrition programme – Poshan Abhiyaan – has been framed as a ‘jan andolan’ or ‘people’s movement’ that makes female undernutrition a collective problem. It focusses on mobilising people to view undernutrition not only as a condition, but as a problem that is unjust, and which must be collectively addressed. Various BCC activities – including ‘Poshan Maah’ (nutrition month), community sensitization activities through PLA approaches, and behaviour change through traditional nutritional recipes – are implemented across the country with participation from a range of stakeholders across public bodies and local communities. (Government of India, 2022). Evidence suggests that the Poshan Abhiyaan has successfully delivered nutritional messaging to a range of female nutrition influencers – including their husbands and mothers-in-law – and has improved knowledge on anaemia prevention (Government of India, 2020). Similarly, India’s Gram Varta Programme seeks to transform community-level attitudes towards female nutrition through participatory approaches and by using women’s Self-Help Groups (SHGs) as agents of change. While women are the intended beneficiaries of this programme, the entire community – including men and service providers – participate actively in the process. An RCT on the Gram Varta programme taught women to be mindful of their health, avoid risks and eat healthy diets. It also empowered them to improve their self-confidence, raise their social capital, and gain male allyship and community trust. Both the Poshan Abhiyaan and Gram Varta programmes stand testament to the power of nutritional social movements in empowering women in highly patriarchal contexts and low-resource settings, thereby tacking harmful gender norms and improving female access to adequate, quality nutrition (Ebert et al., 2017).
Community-level campaigns and social marketing have helped improve female nutrition in a few South Asian contexts. For instance, a nutrition programme in Viet Nam that employed community mobilisation and social marketing helped to improve the consumption of Iron and Folic Acid (IFA) tablets, while causing positive changes in the knowledge, attitudes, and practices (KAP) of women and their family members towards health and nutrition (Khan et al., 2005). In India, the Village Health and Nutrition Day (VHND) is a monthly event that offers nutritional education and counselling, not only to pregnant and lactating women – but to other community members who may influence female nutrition. Several studies within a scoping review have noted that such social campaigns elicit positive behavioural changes and enhance male allyship in matters of female nutrition (Kurian et al., 2021)
Section 4: Conclusions
In sum, female nutrition in South Asia is as much as function of socio-cultural factors and community norms, as it is of poverty and deprivation. In this context, social movements are highly relevant for addressing female nutrition challenges. Notably, social movements target socio-cultural elements, ensure multistakeholder buy-in, and are long-lasting – all of which make them relevant mechanisms for reducing female under-nutrition and ensuring inter-generational behaviour change in South Asia. Further, social movements initiated by the development industry are effective platforms to improve female nutrition, while transforming community behaviours and building social momentum towards women’s rights to food. This is particularly true of low-resource settings, wherein innovative messaging, and movement building, through diverse platforms has proven to be effective in reaching multiple stakeholders and building male allyship in the female nutrition sphere. Evidence shows that such social movements are effective in improving dietary diversity and adequacy for women, and in building community momentum towards women’s nutrition across a range of South Asian contexts.
However, the evidence should be viewed with certain caveats in mind. For one, while there is evidence of improvements in female diets – evidence of overall levels of female malnourishment remains sparse, thereby limiting the evaluability of such social movements. Further, certain social movements are more successful than others: notably, the BCC and PLA approaches have shown more success across diverse settings than other community campaigns and social marketing approaches. However, there are gaps in the evidence base on ‘why’ such approaches to social movement building are more effective than others. This in turn limits the application of successful social movement prototypes across contexts.
One should also remember that such development programme-led social movements are not without their limitations. Firstly, these social movements primarily target pregnant and lactating women, thereby leaving out other categories of women and girls who are vulnerable to under-nutrition. This creates a policy void for the nutritional challenges facing female children, adolescent girls, and older women who face similar risks of malnourishment. Secondly, most development programming-led social movements primarily target women through BCC and PLA approaches: presently, there are fewer programmes that adopt a holistic approach and target other stakeholders (such as women’s families, community leaders). In settings wherein women have limited control over their nutritional choices, targeting other nutrition influencers is significantly more important to realistically make female nutrition a community goal. Finally, these social movements have not been prioritised equally across all South Asian settings. While certain countries like India are spearheading such approaches, less evidence of such social movements comes from other South Asian contexts. This means that such social movements are relatively new, and potentially missing from many South Asian contexts – which limits their reach and impact.
There are implications for both development programming and research. On the programming side, nutrition-focussed social movements would benefit from extending behavioural and participatory approaches to stakeholders and nutrition influencers beyond pregnant and lactating women. Further, such movements should focus on women’s nutrition more holistically – by building community momentum for female nourishment across different female life stages (from birth to old age) rather than only in relation to women’s reproductive functions. On the research side, future evidence generation should focus on understanding the barriers and triggers to nutrition-focussed social movement building across South Asian contexts. To accomplish this, more systematic reviews and evidence syntheses should be developed to capture the role of such social movements in fostering female nutrition outcomes. Further, adopting a realist approach, research should also focus on understanding what styles to movement building work across different settings, and how they contribute to reductions in female malnourishment. This will help fill existing evidence gaps and transfer learnings across contexts– thereby ensuring the portability of such social movements in previously untapped South Asian contexts.
Ash, D., Mahmud, Z., Kappos, K., Ireen, S., & Forissier, T. (2020). Delivery of maternal nutrition interventions at scale and mainstreaming into the health system in Bangladesh. Field Exchange.
Biswas, T., Townsend, N., Magalhaes, R., Hasan, M. M., & Al Mamun, A. (2022). Geographical and socioeconomic inequalities in the double burden of malnutrition among women in Southeast Asia: A population-based study. The Lancet Regional Health-Southeast Asia.
Choudhury, K. K., Hanifi, M. A., Rasheed, S., & Bhuiya, A. (2000). Gender inequality and severe malnutrition among children in a remote rural area of Bangladesh. Journal of Health, Population and Nutrition.
Das Gupta, M. (1990). Death clustering, mothers’ education, and the determinants of child mortality in rural Punjab, India. Population studies.
Fikree, F. F., & Pasha, O. (2004). Role of gender in health disparity: the South Asian context. BMJ.
Gope, R. K., Tripathy, P., Prasad, V., Pradhan, H., Sinha, R. K., Panda, R., … & Prost, A. (2019). Effects of participatory learning and action with women’s groups, counselling through home visits and crèches on undernutrition among children under three years in eastern India: a quasi-experimental study. BMC Public Health.
Harris-Fry, H. A., Paudel, P., Harrisson, T., Shrestha, N., Jha, S., Beard, B. J., … & Saville, N. M. (2018). Participatory women’s groups with cash transfers can increase dietary diversity and micronutrient adequacy during pregnancy, whereas women’s groups with food transfers can increase equity in intrahousehold energy allocation. The Journal of Nutrition.
Hatlebakk, M. (2012). Malnutrition in South-Asia. Poverty, diet, or lack of female empowerment? CMI Working Paper.
ID Insight. (2020). One Year of POSHAN Abhiyaan. Social and Behaviour Change Communication. 2018-2019. Government of India.
Kabeer, N. (1998). Money can’t buy me love? Re-evaluating gender, credit and empowerment in rural Bangladesh. Institute of Development Studies.
Khan, N. C., Thanh, H. T. K., Berger, J., Hoa, P. T., Quang, N. D., Smitasiri, S., & Cavalli-Sforza, T. (2005). Community mobilization and social marketing to promote weekly iron-folic acid supplementation: a new approach toward controlling anemia among women of reproductive age in Vietnam. Nutrition Reviews.
Kumar, N., Scott, S., Menon, P., Kannan, S., Cunningham, K., Tyagi, P., … & Quisumbing, A. (2018). Pathways from women’s group-based programs to nutrition change in South Asia: A conceptual framework and literature review. Global Food Security.
Kurian, K., Lakiang, T., Sinha, R. K., Kathuria, N., Krishnan, P., Mehra, D., … & Sharma, S. (2021). Scoping review of intervention strategies for improving coverage and uptake of maternal nutrition services in Southeast Asia. International Journal of Environmental Research and Public Health.
Lentz, E. C., Narayanan, S., & De, A. (2019). Last and least: findings on intrahousehold undernutrition from participatory research in South Asia. Social Science & Medicine.
Ministry of Women and Child Development. (2022). POSHAN Abhiyaan e-Bulletin. September 2022. Government of India.
Mukherjee, A., Gupta, K. & Sengupta, R. (2020). Country-Led Formative Evaluation of the Maternal and Child Cash Transfer (MCCT) Programme in the Chin and Rakhine States of Myanmar. UNICEF Myanmar.
Nair, S. N., Darak, S., Parsekar, S. S., Menon, S., Parchure, R., Vijayamma, R., … & Nelson, H. (2016). Effectiveness of Behaviour Change Communication (BCC) Interventions in Delivering Health Messages on Antenatal Care for Improving Maternal and Child Health (MCH) Indicators in a Limited Literacy Setting. An Evidence Summary of Systematic Reviews.
Patel, K. A., Langare, S. D., Naik, J. D., & Rajderkar, S. S. (2013). Gender inequality and bio-social factors in nutritional status among under five children attending anganwadis in an urban slum of a town in Western Maharashtra, India. Journal of Research in Medical Sciences.
Ramachandran, N. (2004). Seasonal hunger: Implications for food and nutrition security. Towards Hunger Free India: From Vision to Action.
Ramachandran, N. (2007). Women and food security in South Asia: Current issues and emerging concerns. In Food insecurity, vulnerability and human rights failure (pp. 219-240). Palgrave Macmillan.
Ramakrishnan, U., Lowe, A., Vir, S., Kumar, S., Mohanraj, R., Chaturvedi, A., … & Mason, J. B. (2012). Public health interventions, barriers, and opportunities for improving maternal nutrition in India. Food and Nutrition Bulletin.
Rao, N. (2020). The achievement of food and nutrition security in South Asia is deeply gendered. Nature Food.
Saville, N. M., Shrestha, B. P., Style, S., Harris-Fry, H., Beard, B. J., Sengupta, A., … & Costello, A. (2016). Protocol of the Low Birth Weight South Asia Trial (LBWSAT), a cluster-randomised controlled trial testing impact on birth weight and infant nutrition of Participatory Learning and Action through women’s groups, with and without unconditional transfers of fortified food or cash during pregnancy in Nepal. BMC Pregnancy and Childbirth.
Sen, A. (2003). Missing Women Revisited. BMJ. British Medical Journal (BMJ).
Shafiq, A., Hussain, A., Asif, M., Jameel, A., Sadiq, S., & Kanwel, S. (2021). Determinants of Gender Disparity in Nutritional Intake among Children in Pakistan: Evidence from PDHS. Children.
Siddiqui, F., Salam, R. A., Lassi, Z. S., & Das, J. K. (2020). The intertwined relationship between malnutrition and poverty. Frontiers in Public Health.
Stevens, A., Gilder, M. E., Moo, P., Hashmi, A., Toe, S. E. T., Doh, B. B., … & McGready, R. (2018). Folate supplementation to prevent birth abnormalities: evaluating a community-based participatory action plan for refugees and migrant workers on the Thailand-Myanmar border. Public Health.
Turner, R. H., & Killian, L. M. (1957). Collective behavior (Vol. 3). Englewood Cliffs, NJ: Prentice-Hall.
UNICEF. (2018). Across South Asia, women lack the nutritional care they urgently need. Author.
World Health Organisation. (2021). Malnutrition Fact Sheet. Author.
Editor: Nanditha Menon
Image Credit: JSI