Impacts of women's work and childcare on child illness among Bangladeshi Shodagor communities

For decades, women's employment has been seen as crucial for achieving greater autonomy and empowerment for women, and for promoting better health and nutrition outcomes for children, particularly in low- and middle-income countries (LMIC). However, numerous empirical studies of the relationship between women's work and child outcomes have shown mixed results. Our study tests the assumptions of a model that suggests loss of maternal care during working hours may produce negative health outcomes for children. We use longitudinal data collected from traditionally semi-nomadic, boat-dwelling Shodagor families in Matlab, Bangladesh to determine the importance of maternal care as a mechanism influencing the relationship between women's work and child illness. We use Bayesian linear mixed models to assess the influence of occupation and amount of care on average days of child illness per month, and also to examine the role that allomothers play in buffering against potential negative impacts of lost maternal care on child illness. Results show that children who receive more care from mothers experience fewer days of illness, and that availability of high-quality alloparents mediates the relationship between maternal work and child health. These results indicate that both the care and resources provided by mothers influence children's biological outcomes. This has important implications for policy and aid interventions in LMIC, which have been developed to capitalize on an assumed positive relationship between maternal work and child health and nutrition.

Evidence on Milk Consumption and Production Linkages from Rural Bihar, India

Background

Milk is an important source of protein for many Indian households. However, milk intake is very low. Hence, it is necessary to examine production-consumption linkages of milk within the paradigm of accessibility, availability, and affordability.

Objectives

This study examined linkages between milk consumption and production, accounting for sales and factors associated with production investments in rural Bihar, a major milk-producing state of India with very poor nutritional status.

Methods

A panel of households from the Gaya and Nalanda districts of Bihar were surveyed: the first round in July and August 2019 (n = 2026 households) and the second round from December 2019 to January 2020 (n = 2001 households). Data were collected on household consumption, production, and sale of milk, as well as other foods. The study examines the consumption-production linkage of milk and the association of dietary diversity with consumption from own production, with households as the unit of analysis. Ordinary least square regression analysis of average monthly household milk consumption was used to identify factors associated with milk consumption, particularly milk production.

Results

The median (Quartile 1, Quartile 3) per capita milk consumption per day was 83.3 (41.6, 166.6) mL in the milk-consuming households. Average monthly household milk consumption in liters was higher in milk-producing households [β: 7.1; 95% confidence interval (CI): 6.1, 8.1] than households relying on market purchases. Household milk consumption was higher in the third tertile of milk production than the first tertile of production (β: 14.3 L/wk; 95% CI: 12.1, 17.2) and lower in the highest tertile of household sale quantity (β: -8.8 L/wk in tertile 3, 95% CI: -12.7, -5) than the first tertile of household sale quantity of milk.

Conclusions

The study provides evidence that consumption of milk in rural households is associated with own production such that households with higher production consume more. However, sale preferences restrict the quantity of milk consumed in milk-producing households.

Assessing association of household diet diversity with mother's time use on productive and reproductive activities: a case for gender sensitive social safety nets

OBJECTIVE

In South Asia, while women make substantial economic contributions through their participation in agricultural sector, these contributions are undercounted as most of their work is underpaid or unpaid. This paper examines how mothers allocate their time to productive and reproductive activities and its association with a household's ability to achieve high household diet diversity score.

DESIGN

The analysis uses data on household consumption and expenditure including food during the kharif (June to October) season (seeds are sown) and a modular time-use survey.

SETTING

Two districts of rural Bihar, India.

PARTICIPANTS

Mothers with children less than 5 years of age and supported by the head of the household from 2026 households.

RESULTS

The estimates indicate that the high household diet diversity (High HDDS ≥ 10) is associated with greater time spent in reproductive activities by all women (OR = 1·12, 95 % CI: 1·06, 1·18). However, with increasing time spent in productive activities by the women the odds of achieving 'High HDDS' reduced (OR = 0·83, 95 % CI: 0·77, 0·89) in adjusted logistic regression analysis.

CONCLUSION

The findings highlight propensity to achieve 'High HDDS' in Bihar increased with mothers allocating time towards reproductive activities, while it had an opposing effect with mothers allocating time on productive activities. Our study highlights that the policies that encourage women's participation in agriculture or livestock should acknowledge the unpaid nature of some of the productive activities and design programs to improve economic agency of women to actuate the true potential of agriculture-nutrition pathways.

Women's input and decision-making in agriculture are associated with diet quality in rural Tanzania

Background

Women's empowerment is one critical pathway through which agriculture can impact women's nutrition; however, empirical evidence is still limited. We evaluated the associations of women's participation, input, and decision-making in key agricultural and household activities with women's diet quality.

Methods

We analyzed data from a cross-sectional study of 870 women engaged in homestead agriculture. We used food frequency questionnaires to assess women's diets and computed women's diet quality using the Prime Diet Quality Score (PDQS) (range 0-42), which captures healthy and unhealthy foods. We evaluated women's decision-making in 8 activities, food crop farming, cash crop farming, livestock raising, non-farm economic activities, wage/salary employment, fishing, major household expenditures, and minor household expenditures. Generalized estimating equations (GEE) linear models were used to evaluate associations between (a) women's participation, (b) decision-making, (c) adequate input, (d) adequate extent of independence in decision-making in agriculture, and (e) adequate input in use of agricultural income with their PDQS. Adequate input was defined as input into some, most or all decisions compared to input into few decisions or none. Adequate extent of independence was defined as input to a medium or high extent compared to input to a small extent or none.

Findings

Median PDQS was 19 (IQR: 16-21). Women's adequate input in decision-making on wage and salary employment (estimate: 4.19, 95% CI: 2.80, 5.57) and minor expenditures were associated with higher PDQS vs. inadequate input. Women with independence in decision-making on livestock production (estimate: 0.97, 95% CI: 0.05, 1.90) and minor household expenditures, and women with adequate decision-making in the use of income from wages/salaries (estimate: 3.16, 95% CI: 2.44, 3.87) had higher PDQS. Participation in agricultural activities was positively associated with PDQS.

Conclusions

Women's participation and input in decision-making in wage and salary employment, livestock production, and minor household expenditures were strongly associated with the consumption of better-quality diets. Women participating in multiple farm activities were also likely to have better diet quality. This study adds to the growing evidence on the pathways through which women's empowerment may influence women's nutrition in rural Tanzania.

Evidence-Based Design Process for Nutrition-Sensitive Agriculture Interventions: A Case Study of the Advancing Local Dairy Development Programme in Nigeria

BACKGROUND

Nigeria is a significant contributor to the global burden of chronic undernutrition in children under 5 years of age. The undernutrition challenge constrains the productivity of rural households. This study was carried out among beneficiaries of the productivity-enhancing Nigerian Dairy Development Programme (NDDP) to guide incorporation of nutrition into the successor program-Advancing Local Dairy Development in Nigeria (ALDDN). Therefore, this study contributes to the literature about operationalizing nutrition-sensitive agricultural frameworks.

OBJECTIVE

The study sought to determine potential entry points for improving the nutrition of smallholder dairy farmers (≤ 5 milk cows) with a focus on food system entry points.

METHODS

Primary data were collected from 514 smallholder dairy households in Oyo and Kano states of Nigeria. Both quantitative and qualitative data were collected. Quantitative data collected included minimum dietary diversity for women, nutrition status, and socioeconomic characteristics of households. Qualitative data included information about sources of food, markets, and other food system characteristics. Quantitative data were analysed using descriptive statistical tools and correlation analysis, while common themes were identified from qualitative data.

CONCLUSIONS

The study showcased men's important role in food purchase and consumption, particularly in Kano. Increasing opportunities and the ability of women to use nutrition education appeared necessary for translating knowledge into improved practices. The own consumption (i.e., the portion of the milk kept for households' consumption as well as diversification of foods produced for consumption); income; women's empowerment; and environmental sanitation pathways seemed to be the most feasible pathways for improving nutrition within the context of the study population.

Rainfall, mothers' time use, and child nutrition: evidence from rural Uganda

Care provision is a key component of women's time use with implications for the health and wellbeing of children. Shifting labor demands resulting from weather shocks may imply that women in developing countries have less time for care provision, potentially affecting their children's nutrition. Nonetheless, a broad literature focusing on the indirect impacts of climate change on child nutrition has yet to explore the mechanisms whereby this occurs, and whether mothers' time use is one of these mechanisms. Using the Uganda National Panel Survey, a unique data set that gathers data on farming activities, time use, and anthropometric measures, I analyze how rainfall variability affects mother's time use and whether time use is a mechanism whereby rainfall variability affects child nutrition in the short run (measured as weight-for-age and weight-for-height Z-scores). My results show that increased rainfall variability in the last month decreases mothers' time share in other household-related activities (e.g., fetching water), while it increases the probability of child wasting. Moreover, using mediation analysis, I find that none of the mothers' time-use variables appears to be a mediating factor between rainfall variability and child nutrition. These results suggest that mothers adjust their time use due to rainfall variability without jeopardizing their children's nutritional levels.

Mothers' dietary diversity and associated factors in megacity Dhaka, Bangladesh

Mothers in developing countries are nutritionally vulnerable due to an undiversified diet. Dietary diversity and healthy dietary patterns of mothers are necessary for the health and nutrition of both the mother and the child. Keeping these in mind, the study was designed to investigate the determinants of mothers' dietary diversity in the capital city (Dhaka) of Bangladesh. A total 613 mothers who had at least one child aged 6-59 months were surveyed in 2020. Dietary diversity (DD) was measured by 24 h recall period following the established guidelines. To explore the determinants of dietary diversity, a log linear regression model was employed. The findings revealed that the overall DD of mothers was low, with less than 15% of respondents consuming more than 5 of the 9 food groups. The study found that if a mother receives one more year of formal education, her DD, on average, would increase by 0.70%. Receiving antenatal care (ANC) for four or more times during pregnancy increases DD by 5.13% compared to mothers who receive ANC less than four times. The findings also showed that mothers with access to assets have 10.18% higher DD than mothers without access to assets. On the other hand, mothers' employment status was negatively associated with DD. Redistributing the household workload between mother and other household members can play a critical role in increasing mothers' DD. Providing care facilities and counseling to mothers about the nutritional value of consuming different food groups can substantially improve the situation.

Women's empowerment, production choices, and crop diversity in Burkina Faso, India, Malawi, and Tanzania: a secondary analysis of cross-sectional data

BACKGROUND

Bolstering farm-level crop diversity is one strategy to strengthen food system resilience and achieve global food security. Women who live in rural areas play an essential role in food production; therefore, we aimed to assess the associations between women's empowerment and crop diversity.

METHODS

In this secondary analysis of cross-sectional data, we used data from four cluster-randomised controlled trials done in Burkina Faso, India, Malawi, and Tanzania. We assessed women's empowerment using indicators from the Women's Empowerment in Agriculture Index. Farm-level crop diversity measures were the number of food crops grown, number of food groups grown, and if nutrient-dense crops were grown. We used a two-stage modelling approach. First, we analysed covariate-adjusted country-specific associations between women's empowerment and crop diversity indicators using multivariable generalised linear models. Second, we pooled country-specific associations using random-effects models.

FINDINGS

The final analytic sample included 1735 women from Burkina Faso, 4450 women from India, 547 women from Malawi, and 574 women from Tanzania. Across all countries, compared with households in which women provided input into fewer productive decisions, households of women with greater input into productive decisions produced more food crops (mean difference 0·36 [95% CI 0·16-0·55]), a higher number of food groups (mean difference 0·16 [0·06-0·25]), and more nutrient-dense crops (percentage point difference 3 [95% CI 3-4]). Across all countries, each additional community group a woman actively participated in was associated with cultivating a higher number of food crops (mean difference 0·20 [0·04-0·35]) and a higher number of food groups (mean difference 0·11 [0·03-0·18]), but not more nutrient-dense crops. In pooled associations from Burkina Faso and India, asset ownership was associated with cultivating a higher number of food crops (mean difference 0·08 [0·04-0·12]) and a higher number of food groups (mean difference 0·05 [0·04-0·07]), but not more nutrient-dense crops.

INTERPRETATION

Greater women's empowerment was associated with higher farm-level crop diversity among low-income agricultural households, suggesting that it could help enhance efforts to strengthen food system resilience.

FUNDING

Bill & Melinda Gates Foundation.

Development and validation of a health and nutrition module for the project-level Women's Empowerment in Agriculture Index (pro-WEAI+HN)

Agricultural development projects increasingly aim to improve health and nutrition outcomes, often by engaging women. Although evidence shows such projects can improve women's and children's health and nutrition and empower women, little is known about their impacts on women's health- and nutrition-related agency and the extent to which impacts emerge through women's empowerment, largely due to a lack of instruments that measure the dimensions of women's agency that are directly relevant to health and nutrition outcomes. We developed an optional, complementary module for the project-level women's empowerment in agriculture index (pro-WEAI) to measure health- and nutrition-related agency (pro-WEAI + HN). Our method for developing related indicators used data collected from six agricultural development programmes implemented across Bangladesh, Burkina Faso and Mali (pooled sample = 12,114) and applied psychometric analysis (exploratory and confirmatory factor analysis) and the Alkire-Foster methodology. Results revealed seven indicators covering women's agency in the areas of her own health and diet; her health and diet during pregnancy; her child's diet; breastfeeding and weaning; purchasing food and health products; and acquiring food and health products. Multigroup confirmatory factor analysis revealed measurement invariance across contexts and samples. Tests of association (Cramer's V) and redundancy suggest that the pro-WEAI + HN indicators measured aspects of agency that are distinct from the core pro-WEAI. The uptake of these indicators in studies of nutrition-sensitive agricultural development projects may strengthen the evidence on how such programming can enhance women's empowerment to improve health and nutrition outcomes for themselves and their children.

Intrahousehold power inequalities and cooperation: Unpacking household responses to nutrition-sensitive agriculture interventions in rural India

Nutrition-sensitive agriculture (NSA) interventions offer a means to improve the dietary quality of rural, undernourished populations. Their effectiveness could be further increased by understanding how household dynamics enable or inhibit the uptake of NSA behaviours. We used a convergent parallel mixed-methods design to describe the links between household dynamics-specifically intrahousehold power inequalities and intrahousehold cooperation-and dietary quality and to explore whether household dynamics mediated or modified the effects of NSA interventions tested in a cluster-randomized trial, Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN). We use quantitative data from cross-sectional surveys in 148 village clusters at UPAVAN's baseline and 32 months afterwards (endline), and qualitative data from family case studies and focus group discussions with intervention participants and facilitators. We found that households cooperated to grow and buy nutritious foods, and gendered power inequalities were associated with women's dietary quality, but cooperation and women's use of power was inhibited by several interlinked factors. UPAVAN interventions were more successful in more supportive, cooperative households, and in some cases, the interventions increased women's decision-making power. However, women's decisions to enter into negotiations with family members depended on whether women deemed the practices promoted by UPAVAN interventions to be feasible, as well as women's confidence and previous cultivation success. We conclude that interventions may be more effective if they can elicit cooperation from the whole household. This will require a move towards more family-centric intervention models that empower women while involving other family members and accounting for the varied ways that families cooperate and negotiate.

Agricultural and Socioeconomic Factors Associated with Farmer Household Dietary Diversity in India: A Comparative Study of Visakhapatnam and Sonipat

Using primary data from 479 farmer households, this study examined the associations between agricultural and socioeconomic factors and farmer household dietary diversity in Visakhapatnam and Sonipat. Cropping intensity was positively associated with farmers' household dietary diversity score (HDDS), suggesting that higher cropping intensity may expand the gross cropped area and improve food security among subsistence farmers. Distance to food markets was also significantly associated with farmer HDDS, which suggests that market integration with rural households can improve farmer HDDS in Visakhapatnam. In Sonipat, wealth index had a positive association with farmer HDDS, targeting the income pathway by improving farmer HDDS in this region. Considering the relative contribution of these factors, distance to food markets, cropping intensity, and crop diversity were the three most important factors affecting farmer HDDS in Visakhapatnam, whereas wealth index, cropping intensity, and distance to food markets emerged as the top three important factors contributing to farmer HDDS in Sonipat. Our study concludes that the associations between agricultural and socioeconomic factors and farmer HDDS are complex but context- and location-specific; therefore, considering the site- and context-specific circumstances, different connections to HDDS in India can be found to better support policy priorities on the ground.

How are higher rice yields associated with dietary outcomes of smallholder farm households of Madagascar?

It is widely expected that agriculture would contribute to farmers’ food security and nutrition in developing countries. However, studies that directly explore the link between agricultural productivity and micronutrients intake by farmers are scarce. In this paper, we contribute to filling this gap by exploring two key channels by which agricultural production can influence dietary outcomes: a food consumption pathway and a cash revenue pathway. To achieve this, we used three-years panel data of rice farmers collected in the Vakinankaratra region of Madagascar. The results suggest that rice yield is positively and significantly associated with farmers’ calorie and micronutrients intake, though the observed elasticities are low. Secondly, raising rice yield has a positive significant impact not only on rice consumption but also on the share of the output sold and the cash revenue from rice sales. Lastly, the results suggest that households with higher cash revenue from rice sales purchase more nutritious foods. Therefore, we conclude that the market represents the channel through which increased rice yield translates into improved micronutrient intake. The findings of this study imply that in order to improve farm households’ nutrition through agricultural production, interventions that target yield enhancement should be accompanied by market access measures.

Household Dietary Diversity among the Ethnic Minority Groups in the Mekong Delta: Evidence for the Development of Public Health and Nutrition Policy in Vietnam

Poor household dietary diversity has been linked to malnutrition in individuals, households, and cumulatively in populations. High rates of malnutrition among Khmer ethnic children aged five years and younger have been reported in Tri Ton district, Vietnam. This paper aims to further investigate household dietary diversity and associated factors among Khmer ethnic minority populations in Vietnam. A cross sectional study was conducted from October 2018 to April 2019 in Tri Ton District, An Giang Province. By employing a multistage sampling technique, a total of 402 (99.8% response rate) participants were interviewed to measure household dietary diversity using a structured and validated questionnaire developed by FAO. Both bivariate and multivariate logistic regression analyses were carried out to identify factors associated with household dietary diversity. The results showed that the prevalence of low, medium and high dietary diversity scores were 21.4%, 70.4% and 8.2%, respectively. Male-headed households, literacy level, household income, exposure to mass media on nutrition and health information, and frequency of eating were positively associated with household dietary diversity (p < 0.05). However, owning a vegetable and rice farm was not statistically related to households’ dietary diversification. The paper concludes that the magnitude of household diversified dietary intakes was essentially low to medium in participants’ households. These findings have provided evidence to inform the development of the National Nutrition Strategy—2021−2030 in Vietnam, to be revised in 2045. This national strategy proposes appropriate interventions, programs and policies to improve socioeconomic status in ethnic groups and in mountainous areas to enhance populations’ health and well-being including controlling childhood malnutrition. In order to improve population health and wellbeing in Tri Ton District, further actions to address effective dietary practices including strengthening nutrition and health communication about the need to improve household dietary diversity to high levels are recommended.

Enhancing female status by improving nutrition: the role of corporate social responsibility in Nigeria’s oil region

Purpose

The purpose of this paper is to critically examine the multinational oil companies’ (MOCs) corporate social responsibility (CSR) initiatives in Nigeria. Its special focus is to investigate the impact of the global memorandum of understanding (GMoU) on improving female status by improving nutrition in the Niger Delta region of Nigeria.

Design/methodology/approach

This paper adopts a survey research technique, aimed at gathering information from a representative sample of the population, as it is essentially cross-sectional, describing and interpreting the current situation. A total of 768 women respondents were sampled across the rural areas of the Niger Delta region.

Findings

The results from the use of a combined propensity score matching and logit model indicate that GMoU model has made significant impact in the key areas of assessment – gender-sensitive nutrition education, food security at household level, reduction on food taboos and female access to education.

Practical implications

This suggests that CSR interventions targeting to improve the nutrition status of girls and adolescents will help to ensure that female’s status improves throughout the life circle in the region.

Social implications

This implies that MOCs’ investment in the nutrition of female is an important short-term barometer in assessing expected returns to improving household nutrition and overall human development capacity for sub-Saharan Africa.

Originality/value

This research contributes to the inequality debate in the women’s nutrition and inclusive growth literature from the CSR perspective. It concludes that business has an obligation to help in solving problems of public concern.

Women's Empowerment, Food Security, and Nutrition Transition in Africa

Despite mounting recognition of the essential role of women's empowerment in household dietary and nutrition changes, the diversity of culture across African countries presents ambiguity as to whether its impact is experienced homogeneously across the continent. This article presents a systematic review of whether women's empowerment changes household dietary patterns, contributes to nutrition improvement, and consequently affects diet-related health outcomes in Africa. We find that whilst more research needs to be conducted, particularly with improved methodologies that can establish cause-effect relationships, there is consensus among the literature on the link between women's empowerment and some domains of food security and dietary improvement. Meanwhile, studies on women's empowerment and the additional demand pressure on some food categories are quite limited. This exacerbates the challenge of setting production plans that aim to address the continent's question of food.

Qualitative evidence for improved caring, feeding and food production practices after nutrition-sensitive agriculture interventions in rural Vietnam

Background

Research on nutrition-sensitive agriculture (NSA) has mostly been aimed at demonstrating its impact on nutrition and explicating underlying pathways, and more rarely at understanding processes and lessons learnt from them. This study aimed to gain insights into the processes that influence behaviour change, contributing to improved caring, feeding and food production practices, using a program theory perspective. It also investigated perceived challenges to the sustainability of interventions and potential solutions, in the context of an NSA program in rural Vietnam. Using a participatory approach, data were gathered on impact pathways and perceived outcomes, on elements of program theory that led to behavioural change, as well as barriers and facilitators. Respondents in semi-structured interviews (n = 30) and seven focus group discussions (total n = 76) were selected purposively among program participants. Data was collected and triangulated across several stakeholder groups.

Results

The impact pathways (production-consumption, caring and feeding, and home-grown school feeding) envisaged in the NSA program functioned as intended; synergies were revealed. The increased supply of locally produced nutrient-rich foods not only contributed to the emergence of a promising income sub-pathway but also reinforced synergy with the home-grown school feeding pathway. Improved diets, feeding and caring practices, and school attendance were key outcomes of the program. Successful elements were pathway-specific, such as flexibility in implementing context-appropriate agricultural models. Others, such as benefit-driven motivation and improved knowledge, triggered changes in multiple pathways. Role models, increased self-confidence, and change agents were the main process facilitators. The biggest barrier to both implementation and sustainability was the poor socio-economic conditions of the most disadvantaged households.

Conclusions

This study showed the relevance of NSA programs in addressing undernutrition in remote areas by enhancing self-reliance in local communities. The integration of behaviour change activities proved to be a key strategy in the process to enhance the impact of agriculture on nutrition outcomes. Though outcomes and influencing factors are very context-dependent, lessons on what worked and what did not work could inform the design and implementation of effective behaviour change strategies in future NSA programs in Vietnam and elsewhere.

Guest Editors' Introduction: The role of policy in reducing malnutrition in sub-Saharan Africa

Sub-Saharan African countries experience various market failures and other constraints in food production, marketing, and food consumption. Consequently, sub-Saharan Africa governments have put in place a myriad of policies to counter these failures. Agricultural, food and nutrition policies address nutrition outcomes, such as hunger, undernourishment, wasting, stunting, child mortality, inadequate food consumption, food insecurity, and volatile food prices, thus improve nutrition outcomes among the population. However, malnutrition persists among the population in the region. To mitigate this challenge, informed, evidence-based policy development and implementation by policy practitioners is of essence. The solutions to the double burden of undernutrition and obesity cut across the agriculture, rural development, and public health sectors. This essay introduces twenty papers of this Special Issue of the Food Policy journal which analyzes 8 policy domains, contributes to the debate on the linkages and pathways through which policies influence food security, nutrition outcomes, and related indicators and points to policy directions in these domains.

Understanding the effects of nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings on maternal and child nutrition in rural Odisha, India: A mixed‐methods process evaluation

A trial of three nutrition‐sensitive agriculture interventions with participatory videos and women's group meetings in rural Odisha, India, found improvements in maternal and child dietary diversity, limited effects on agricultural production, and no effects on women and children's nutritional status. Our process evaluation explored fidelity, reach, and mechanisms behind interventions' effects. We also examined how context affected implementation, mechanisms, and outcomes. We used data from intervention monitoring systems, review notes, trial surveys, 32 case studies with families (n = 91 family members), and 20 group discussions with women's group members and intervention workers (n = 181 and 32, respectively). We found that interventions were implemented with high fidelity. Groups reached around half of the mothers of children under 2 years. Videos and meetings increased women's knowledge, motivation and confidence to suggest or make changes to their diets and agricultural production. Families responded in diverse ways. Many adopted or improved rainfed homestead garden cultivation for consumption, which could explain gains in maternal and child dietary diversity seen in the impact evaluation. Cultivation for income was less common. This was often due to small landholdings, poor access to irrigation and decision‐making dominated by men. Interventions helped change norms about heavy work during pregnancy, but young women with little family support still did considerable work. Women's ability to shape cultivation, income and workload decisions was strongly influenced by support from male relatives. Future nutrition‐sensitive agriculture interventions could include additional flexibility to address families’ land, water, labour and time constraints, as well as actively engage with spouses and in‐laws.

In rural eastern India, participatory videos and women's group meetings on agriculture and maternal and child nutrition increased women's knowledge, motivation and confidence to improve their and their children's diets.

Given strong constraints linked to small landholdings, poor access to water and gender norms which meant that in‐laws' and husbands' assent or support were often required for cultivation decisions, many women responded to interventions by increasing rainfed homestead garden cultivation for consumption rather than cultivating for income.

Women's and children's diets may have improved because of discussions about nutrition and an increase in homestead garden cultivation. These dietary changes alone were likely insufficient to improve women's and children's nutritional status.

The interventions’ ability to influence the adoption of nutrition‐sensitive agriculture practices could be improved by being family‐centric: understanding women's decision‐making power in a family context, using tailored problem‐solving to address households' individual constraints to cultivation, and including women's husbands and in‐laws.

The associations between women's empowerment measures, child growth and dietary diversity: Findings from an analysis of demographic and health surveys of seven countries in Eastern Africa

Evidence on the efficacy of women's empowerment to improve child growth and minimum dietary diversity (MDD) in the Eastern Africa (EA) region is limited. This cross‐sectional study used recent Demographic and Health Survey data of mother–child dyads from seven countries in EA to examine the associations between women's empowerment measures, child growth and MDD. Length‐for‐age z‐scores, weight‐for‐length z‐scores and weight‐for‐age z‐scores were used to categorize growth indicators of 6–23 months old children. Multivariable logistic regression was used to identify significant associations. Among all countries, 32%–59% of children experienced growth failure. Children meeting MDD were 18%–45%. Women having self‐esteem were associated with lower odds of stunting (adjusted odds ratio [AOR] = 0.62 in Rwanda), wasting (AOR = 0.38 in Uganda), underweight (AORs = 0.60 and 0.57 in Tanzania and Uganda, respectively) and growth failure (AOR = 0.64 in Rwanda). Having health decision control in Burundi was associated with lower odds of stunting (AOR = 0.49) and child growth failure (AOR = 0.52) and higher odds of meeting MDD (AOR = 2.50). Having Legal empowerment among women increased the odds of stunting (AOR = 1.79 in Burundi), underweight (AOR = 1.77 in Uganda) and growth failure (AOR = 1.87 in Burundi). Economic empowerment showed mixed associations with child growth and MDD among some countries. Women's self‐esteem and health decision control were associated with better child growth and MDD for some countries in EA. Nutrition‐sensitive interventions aimed at improving child growth and MDD should consider local contexts when addressing women's empowerment.

Understanding the associations between women's empowerment, child growth and child dietary diversity is important for most nutrition‐sensitive interventions seeking to improve child feeding practices and growth by targeting mothers.

In this study, for women to have self‐esteem and health decision control was consistently beneficial for child growth and minimum dietary diversity (MDD). Mixed associations existed among other women's empowerment measures, child growth and MDD across the seven East African countries investigated.

For improved child growth and better child dietary diversity, targeting specific women's empowerment measures based on local context may be beneficial in the East African region.

Impact of a homestead food production program on women's empowerment: Pro-WEAI results from the FAARM trial in Bangladesh

Nutrition-sensitive agricultural programs have the potential to improve women's and children's nutrition, along with women's empowerment. The project-level Women's Empowerment in Agriculture Index (pro-WEAI) aims to standardize the measurement of women's agency and enable the assessment of impact over typical project timelines. Within the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Habiganj, Sylhet, Bangladesh, we examined quantitative pro-WEAI data collected from a subsample of trial participants and their husbands (n = 885) approximately four months after the end of the intervention. We evaluated the impact of a three-year homestead food production program on men's and women's agency separately by pro-WEAI domain and indicator, using multilevel logistic and linear regression. We show that women in the FAARM intervention group had levels of agency similar to men and much higher than women in the control group (Odds Ratio [OR] 7.7, p < 0.001), corresponding to better gender equity in intervention areas (OR 3.5, p < 0.001). The higher levels of agency among intervention women were driven by greater intrinsic and collective agency but not by instrumental agency. Compared to controls, more women in the intervention group found intimate partner violence unacceptable (OR 3.5, p < 0.001), had greater ownership of assets (OR 2.6, p = 0.001), better control of income (OR 1.8, p = 0.042), higher levels of group membership (OR 14.0, p < 0.001), and membership in groups they considered influential (OR 166.8, p < 0.001). Self-efficacy was greater in intervention areas for both women (OR 3.2, p < 0.001) and men (OR 2.3, p = 0.002). Our results contribute to the development of benchmarks for interpreting pro-WEAI scores across programs. Our assessment of the impact of a homestead food production program on women's agency provides additional rationale for women-led agricultural projects. We plan to build on these findings by examining the role of improved women's agency on the pathway from the intervention to nutritional impacts.

Changing food systems and infectious disease risks in low-income and middle-income countries

The emergence of COVID-19 has drawn the attention of health researchers sharply back to the role that food systems can play in generating human disease burden. But emerging pandemic threats are just one dimension of the complex relationship between agriculture and infectious disease, which is evolving rapidly, particularly in low-income and middle-income countries (LMICs) that are undergoing rapid food system transformation. We examine this changing relationship through four current disease issues. The first is that greater investment in irrigation to improve national food security raises risks of vector-borne disease, which we illustrate with the case of malaria and rice in Africa. The second is that the intensification of livestock production in LMICs brings risks of zoonotic diseases like cysticercosis, which need to be managed as consumer demand grows. The third is that the nutritional benefits of increasing supply of fresh vegetables, fruit, and animal-sourced foods in markets in LMICs pose new food-borne disease risks, which might undermine supply. The fourth issue is that the potential human health risks of antimicrobial resistance from agriculture are intensified by changing livestock production. For each disease issue, we explore how food system transition is creating unintentional infectious disease risks, and what solutions might exist for these problems. We show that successfully addressing all of these challenges requires a coordinated approach between public health and agricultural sectors, recognising the costs and benefits of disease-reducing interventions to both, and seeking win-win solutions that are most likely to attract broad policy support and uptake by food systems.

Seasonal variability of women's dietary diversity and food supply: a cohort study in rural Burkina Faso

OBJECTIVE

To investigate the seasonal variations of women's dietary diversity (WDD) (items consumed and food supply) and its linkages with agriculture, market and wild resources.

DESIGN

A cohort of 300 women was followed-up over a year to investigate WDD and food sources (production, purchase or foraging). Monthly qualitative 24 h recalls allowed computing WDD Scores from a standard 10-food groups (FG) classification (WDDS-10). Associations between farm/women's characteristics and WDDS-10 were investigated using multivariate mixed models including interaction terms factor*months.

SETTING

Tuy province, Burkina Faso.

PARTICIPANTS

300 women of reproductive age.

RESULTS

Both dietary diversity and food sources were seasonal. The mean WDDS-10 was relatively stable from August to January (ranging from 3·1 to 3·5 FG) when farm production predominated. The WDDS-10 gradually increased from February, concomitantly with an increase in food purchases (onions, tomatoes, mangoes) and reached its highest levels (>4 FG) from March to June, when food purchases were still relatively high and when more women consumed foraged fruits (shea plums and wild grapes). Women living on farms owning > 3 plough oxen and different animal species had significantly higher WDDS-10 than others (+0·28 and +0·35 FG, respectively). Women who practiced off-farm activities also had higher WDDS-10 than those who did not (+0·21 FG, P < 0·05). Other factors, for example, the number of foraged edible species, provided advantages in terms of dietary diversity only during certain seasons (October - January, P for interaction < 0·01).

CONCLUSIONS

Diversifying women's diets throughout the year requires complementary interventions aimed at diversifying production, promoting foraging and increasing income-generating activities to enable food purchasing.

Market access and dietary diversity: A spatially explicit multi-level analysis in Southern and Western Kenya

The risk of malnutrition, particularly micronutrient deficiency, is high in large parts of Sub-Saharan Africa for smallholder farmers. Access to diverse and nutritious food is a key component of food security, and a major development objective. It is widely accepted that good access to markets can play a key role in improving nutrition at the foodshed level. However, the magnitude and even the direction of the effect of increased market access on household dietary diversity (and thus food security) is not universal, with studies showing divergent results. One reason for these divergences may be that models do not account for place-based mediation effects, that is, farmers' local context can affect whether (and the extent to which) access to market is important to their nutrition. Drawing on household survey data from 914 Kenyan smallholder farmers from ten counties in South and West Kenya, we used a novel methodology to evaluate the role of market access in determining household dietary diversity. This methodology combines the clustering of households along places with similar characteristics and multi-level regression analysis to understand the place based variation in effects of different factors on dietary diversity. We found that, depending on how “access to market” is measured, there can be significant impacts on dietary diversity, and this is mediated by farm characteristics. For small farms with already good market access, higher diet diversity is associated with cultivating larger areas and owning larger livestock holdings, but not with easier market access. For isolated larger farms with a focus on livestock production, higher diet diversity is associated with easier market access (i.e., proximity to road), as well as greater livestock diversity. For medium-sized farms with good market access, diet diversity is mildly correlated with easier market access (i.e., proximity to road) but significantly associated with greater crop diversity. The need to account for place-based mediating effects is clearly important and highlights an exigency for greater use and development of localized models that can capture the extent to which effects might change when contexts change.

Cameras in the Hands of Indigenous Youth: Participation, Films, and Nutrition in India

Background

Indigenous communities in India have diets that do not fulfill all of their minimum nutritional requirements. Given the unaffordability of healthy diets, these communities rely on common-pool resources to make up for shortfalls in food. Yet, such foods are devalued as "backward," and accessing them is regulated by unequal gendered roles.

Objectives

To explore the central role of community participation in documenting and transmitting indigenous knowledge about the role of locally available foods in improving dietary diversity.

Methods

Through a participatory action research approach, 10 Santhal youth were trained to make films about a range of locally available foods and other issues of concern to them (Santhal/Santal is a native ethnic group in India). These films were broadcast on a YouTube channel and screened locally. A thematic content analysis of 49 films was undertaken, alongside interviews with the filmmakers and focus group discussions with viewers who attended 4 film screenings.

Results

A majority of the films produced drew on intergenerational and indigenous knowledge about edible plants, insects, and rodents; skills in foraging and preparing food; awareness of the benefits of the food; and sustainability issues across the traditional food systems. The filmmakers initially focused on responding to community needs and showcasing Santhal cultural practices. Their later films began to reflect on aspects of their culture that needed to be preserved, revived, or modified. Audiences noted the relatability and relevance of the provided information, generated ideas and priority themes for further documentation, and expressed the need for revival and modification of certain cultural food practices.

Conclusion

A participatory filmmaking process in the context of community nutrition can enable participants to question unequal power relations by enabling the most marginalized to voice their own perspectives with the support of cameras and filmmaking skills.

The Indirect Impact of Smallholder Vegetable Production on Children's Nutrition Outcomes in Rural Vietnam

Childhood undernutrition, particularly stunting, wasting, and micronutrient deficiencies, remains a major health concern in rural Vietnam. While literature suggests leveraging agriculture to improve child nutrition via agricultural diversification, market engagement, and women's empowerment, very few studies have empirically explored how smallholder vegetable production can influence household nutrition. This paper examines the association of household-level vegetable diversity, market access, and market participation with nutrition outcome measures of children in smallholder households. We use a cross-sectional household dataset, collected in 2016 in northwest Vietnam, covering 234 children aged 6–60 months. We estimate and compare the results of regression models using three-stage least squares (3SLS), ordinary least squares (OLS), logistic regression, and seemingly unrelated regression (SUR), to explore variations in six nutrition outcome measures: height-for-age z-score (HAZ), weight-for-height z-score (WHZ), weight-for-age z-score (WAZ), stunting, wasting, and underweight. Our results suggest smallholder vegetable production has a significant indirect association with children's nutrition status via market participation. Market participation is an important factor in improving girls' HAZ and WHZ, and in reducing the probability of boys being stunted and underweight. The additional income from selling vegetables allows households to purchase nutritious food, which is likely to have a positive impact on children's nutrition outcomes.

A simplified measure of nutritional empowerment: Using machine learning to abbreviate the Women's Empowerment in Nutrition Index (WENI)

Measuring empowerment is both complicated and time consuming. A number of recent efforts have focused on how to better measure this complex multidimensional concept such that it is easy to implement. In this paper, we use machine learning techniques, specifically LASSO, using survey data from five Indian states to abbreviate a recently developed measure of nutritional empowerment, the Women's Empowerment in Nutrition Index (WENI) that has 33 distinct indicators. Our preferred Abridged Women's Empowerment in Nutrition Index (A-WENI) consists of 20 indicators. We validate the A-WENI via a field survey from a new context, the western Indian state of Maharashtra. We find that the 20-indicator A-WENI is both capable of reproducing well the empowerment scores and status generated by the 33-indicator WENI and predicting nutritional outcomes such as BMI and dietary diversity. Using this index, we find that in our Maharashtra sample, on average, only 35.9% of mothers of children under the age of 5 years are nutritionally empowered, whereas 77.2% of their spouses are nutritionally empowered. We also find that only 14.6% of the elderly women are nutritionally empowered. These estimates are broadly consistent with those based on the 33-indicator WENI. The A-WENI will reduce the time burden on respondents and can be incorporated in any general purpose survey conducted in rural contexts. Many of the indicators in A-WENI are often collected routinely in contemporary household surveys. Hence, capturing nutritional empowerment does not entail significant additional burden. Developing A-WENI can thus aid in an expansion of efforts to measure nutritional empowerment; this is key to understanding better the barriers and challenges women face and help identify ways in which women can improve their nutritional well-being in meaningful ways.

Vegetables for Healthy Diets in Low- and Middle-Income Countries: A Scoping Review of the Food Systems Literature

BACKGROUND

Vegetables are an essential element in healthy diets, but intakes are low around the world and there is a lack of systematic knowledge on how to improve diets through food system approaches.

METHODS

This scoping review assessed how studies of food systems for healthy diets have addressed the role of vegetables in low- and middle-income countries. We apply the PRISMA guidelines for scoping reviews to narratively map the literature to an accepted food systems framework and identify research gaps.

RESULTS

We found 1383 relevant articles, with increasing numbers over 20 years. Only 6% of articles looked at low-income countries, and 93% looked at single-country contexts. Over half of articles assessed vegetables as a food group, without looking at diversity within the food group. 15% looked at traditional vegetables. Issues of physical access to food were among the least studied food system topics in our review (7% of articles). Only 15% of articles used a comprehensive food system lens across multiple dimensions. There is also a research gap on the impacts of different policy and practice interventions (13% of articles) to enable greater vegetable consumption.

CONCLUSIONS

Food system studies necessarily drew on multiple disciplines, methods and metrics to describe, analyze, and diagnose parts of the system. More work is needed across disciplines, across contexts, and across the food system, including understanding interventions and trade-offs, and impacts and change for diets particularly of marginalized population groups. Filling these gaps in knowledge is necessary in order to work toward healthy vegetable-rich diets for everyone everywhere.

Validation of an Automated Wearable Camera-Based Image-Assisted Recall Method and the 24-h Recall Method for Assessing Women's Time Allocation in a Nutritionally Vulnerable Population: The Case of Rural Uganda

Accurate data are essential for investigating relationships between maternal time-use patterns and nutritional outcomes. The 24 h recall (24HR) has traditionally been used to collect time-use data, however, automated wearable cameras (AWCs) with an image-assisted recall (IAR) may reduce recall bias. This study aimed to evaluate their concurrent criterion validity for assessing women’s time use in rural Eastern Ugandan. Women’s (n = 211) time allocations estimated via the AWC-IAR and 24HR methods were compared with direct observation (criterion method) using the Bland–Altman limits of agreement (LOA) method of analysis and Cronbach’s coefficient alpha (time allocation) or Cohen’s κ (concurrent activities). Systematic bias varied from 1 min (domestic chores) to 226 min (caregiving) for 24HR and 1 min (own production) to 109 min (socializing) for AWC-IAR. The LOAs were within 2 h for employment, own production, and self-care for 24HR and AWC-IAR but exceeded 11 h (24HR) and 9 h (AWC-IAR) for caregiving and socializing. The LOAs were within four concurrent activities for 24HR (−1.1 to 3.7) and AWC-IAR (−3.2 to 3.2). Cronbach’s alpha for time allocation ranged from 0.1728 (socializing) to 0.8056 (own production) for 24HR and 0.2270 (socializing) to 0.7938 (own production) for AWC-IAR. For assessing women’s time allocations at the population level, the 24HR and AWC-IAR methods are accurate and reliable for employment, own production, and domestic chores but poor for caregiving and socializing. The results of this study suggest the need to revisit previously published research investigating the associations between women’s time allocations and nutrition outcomes.

Maternal and paternal involvement in complementary feeding in Kaduna State, Nigeria: The continuum of gender roles in urban and rural settings

Household gender roles influence infant and young child feeding behaviours and may contribute to suboptimal complementary feeding practices through inequitable household decision‐making, intra‐household food allocation and limited paternal support for resources and caregiving. In Igabi local government area of Kaduna State, Nigeria, the Alive & Thrive (A&T) initiative implemented an intervention to improve complementary feeding practices through father engagement. This study describes household gender roles among A&T participants and how they influence maternal and paternal involvement in complementary feeding. We conducted 16 focus group discussions with mothers and fathers of children aged 6–23 months in urban and rural administrative wards and analysed them using qualitative thematic analysis methods. Most mothers and fathers have traditional roles with fathers as ‘providers’ and ‘supervisors’ and mothers as ‘caregivers’. Traditional normative roles of fathers limit their involvement in ‘hands‐on’ activities, which support feeding and caring for children. Less traditional normative roles, whereby some mothers contributed to the provision of resources and some fathers contributed to caregiving, were also described by some participants and were more salient in the urban wards. In the rural wards, more fathers expressed resistance to fathers playing less traditional roles. Fathers who participated in caregiving tasks reported respect from their children, strong family relationships and had healthy home environments. Our research findings point to the need for more context‐specific approaches that address prevalent gender normative roles in complementary feeding in a variety of settings.

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Some mothers and fathers still hold traditional attitudes about their roles in feeding and caring for children.

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Traditional gender normative roles of fathers limit their involvement in the ‘hands‐on’ activities that support feeding and caring for children.

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Some mothers and fathers are performing ‘non‐traditional’ gender normative roles despite social disapproval.

•

The shifts from the traditional roles of mothers and fathers are more salient in urban compared with rural wards.

Oil palm and gendered time use: A mixed-methods case study from West Kalimantan, Indonesia

Measuring the social impact of oil palm requires the use of multiple metrics which capture different dimensions of well-being. To date, most studies have examined welfare outcomes at the household level, relying on a relatively narrow range of indicators. There is a need for a more diverse range of metrics to measure the social impacts of oil palm as well as more explicit accounting for study context and gendered effects. Here we demonstrate the utility of specialised time use methods used in combination with qualitative research to understand intra-household labour dynamics associated with oil palm adoption. We use a mixed-methods approach to investigate the role of smallholder oil palm plasma schemes on men and women's time use in Kapuas Hulu District, West Kalimantan. Time allocation is an important determinant of well-being as well as maternal and child nutrition and an indicator of women's empowerment and gender equality. We integrate the results from a fractional multinomial logistic regression of data from 603 individuals with qualitative findings on the subjective experience of time allocation, as well as, the causes, consequences and coping strategies to manage trade-offs in time allocation. We find that relative to non-oil-palm adopting swidden farmers, participation in oil palm plasma schemes is associated with more time spent in productive labour for both men and women, driven by off-farm labour on oil palm plantations. For women, increased time comes at the cost of reduced time spent in rest, leisure and sleep. Increased time spent in off-farm labour drives households to adapt agricultural production methods, changing cash crop production as well as accelerating swidden transitions. These changes alter gender dynamics and responsibilities within the household. Our results suggest that changes in time allocation may have significant consequences for women's well-being and gender equity. Women in the oil palm site experienced greater stress over time scarcity and employed coping strategies more frequently. Our findings indicate that time allocation could be used as an indicator of the effects of oil palm expansion and adoption on well-being and that potential effects of time scarcity on well-being, gender equity, and maternal and child nutrition should be considered by policy makers when making land use decisions.

Maternal Participation Level in a Nutrition-Sensitive Agriculture Intervention Matters for Child Diet and Growth Outcomes in Rural Ghana

Background

Little is known about how the level of program participation affects child nutrition in rural interventions.

Objectives

This study examined the association between participation level in a nutrition-sensitive agriculture intervention and children's diet and anthropometric outcomes in rural Ghana.

Methods

Nutrition Links was a cluster randomized controlled trial (clinicaltrials.gov NCT01985243), which enrolled caregivers with children (aged less than 2 mo in 2014-2015 and less than 18 mo in 2016-2017). Of the 287 caregivers in 19 intervention communities who enrolled, 233 adopted the intervention and received layer poultry, garden inputs, and weekly child feeding education. The egg production and repayment of poultry were monitored, and feed was sold at the weekly meetings. After endline, the nutrition educators rated each woman who adopted the intervention on a scale [very poor (1) to excellent (5)] for: 1) meeting attendance, 2) egg productivity, 3) feed and poultry loan payment, 4) contributions during meetings, and 5) attentiveness towards group members. Participation level was classified as high, medium, and low by dividing the sum of these 5 items into tertiles; 54 women who did not adopt the intervention were classified as "no participation." Generalized mixed linear models tested the difference in changes in children's diet and anthropometric indices between the participation levels and the control category - 213 caregiver-child dyads in 20 communities who received standard-of-care health and agricultural services.

Results

Compared with the control category, only high participation was associated with egg consumption [adjusted OR (aOR) = 3.03; 95% CI: 1.15, 7.94]. Both medium and high participation levels were associated with length-for-age z-scores (LAZ)/height-for-age z-scores (HAZ) [adjusted β-coefficients (aβ) = 0.44; 95% CI: 0.16, 0.72 and 0.40; 95% CI: 0.12, 0.67, respectively].

Conclusion

These results highlight the importance of promoting and monitoring the level of beneficiary participation to estimate the full potential of nutrition-sensitive agriculture interventions to improve nutritional outcomes.

Farm production diversity and women's dietary diversity: Evidence from central Tunisia

In the context of studies on the effects of agricultural production diversity, there are debates in the scientific community as to the level of diversification appropriate for improving dietary diversity. In Tunisia, agriculture is a strategic sector for the economy and a critical pillar of its food sovereignty. Using instrumental variable methods to account for endogeneity, we have estimated the association between agricultural production diversity and women's dietary diversity among smallholder farming households in the Sidi Bouzid governorate (central Tunisia). Although we found a low level of agricultural production diversity and a fairly diversified diet among women, we observed a systematic weak positive association between five different indicators of agricultural production diversity and women's dietary diversity. We observed a stronger positive association between women's dietary diversity and women being more educated and households being wealthier. Neither diversity of food supplies in food markets nor market distance were associated with women's dietary diversity, whereas we observed a higher level of consumption of some products (dairy) when they were produced on the farm.

Reshaping Food Policy and Governance to Incentivize and Empower Disadvantaged Groups for Improving Nutrition

The coronavirus disease 2019 (COVID-19) pandemic has exacerbated global malnutrition challenges, disrupted food supply chains, and left poor and vulnerable people unable to produce and access safe and affordable food, especially in developing countries. Food policy and governance are currently malfunctioning, despite their recognized roles in improving food security and public nutrition in many local and national contexts. This article reviews existing food policies and governance with implications for disadvantaged groups in the food systems, particularly smallholder farmers, women, and small- and medium-sized enterprises (SMEs), highlighting the importance of reshaping food policies and governance. To end malnutrition in the post-COVID era, multiple sectors, including health, agriculture, social protection, education, and infrastructure, must make greater collaborative efforts to develop and implement food and nutrition policies. Several recommendations for reshaping food policy interventions and governance are summarized.

Connecting the food and agriculture sector to nutrition interventions for improved health outcomes

To achieve the Sustainable Development Goal of zero hunger, multi-sectoral strategies to improve nutrition are necessary. Building towards this goal, the food and agriculture sector must be considered when designing nutritional interventions. Nevertheless, most frameworks designed to guide nutritional interventions do not adequately capture opportunities for integrating nutrition interventions within the food and agriculture sector. This paper aims to highlight how deeply connected the food and agriculture sector is to underlying causes of malnutrition and identify opportunities to better integrate the food and agriculture sector and nutrition in low and middle income countries. In particular, this paper: (1) expands on the UNICEF conceptual framework for undernutrition to integrate the food and agriculture sector and nutrition outcomes, (2) identifies how nutritional outcomes and agriculture are linked in six important ways by defining evidence-based food and agriculture system components within these pathways: as a source of food, as a source of income, through food prices, women's empowerment, women's utilization of time, and women's health and nutritional status, and (3) shows that the food and agriculture sector facilitates interventions through production, processing and consumption, as well as through farmer practices and behavior. Current frameworks used to guide nutrition interventions are designed from a health sector paradigm, leaving agricultural aspects not sufficiently leveraged. This paper concludes by proposing intervention opportunities to rectify the missed opportunities generated by this approach. Program design should consider the ways that the food and agriculture sector is linked to other critical sectors to comprehensively address malnutrition. This framework is designed to help the user to begin to identify intervention sites that may be considered when planning and implementing multi-sectoral nutrition programs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-022-01262-3.

Diversify, produce or buy? An analysis of factors contributing to household dietary diversity among shrimp and non-shrimp farmers in coastal Bangladesh

Until the Covid-19 pandemic, Bangladesh had reported consistent improvements regarding its food and nutrition security (FNS) status, and yet, the country still features poor FNS outcomes among parts of its population. In rural coastal regions of the Ganges–Brahmaputra-Meghna delta, farming households’ vulnerability is particularly exacerbated by a range of environmental hazards, increasing challenges for agriculture to contribute to higher FNS levels. In the context of existing literature on the trade-offs between subsistence agriculture and cash-earning livelihood activities, vis-à-vis food and nutrition security outcomes, this article assesses the relative contribution of crop diversification vis à vis other factors on the households’ Food Consumption Score (FCS) in specific livelihood contexts. We provide differentiated analyses between primarily export-oriented shrimp farming and non-shrimp farming households, so policy makers can better address FNS targets. Quantitative data from 1,188 sample households across the delta were analysed through descriptive and linear regression analyses. Results show that households cultivating shrimp have a significantly higher dietary diversity than households that do not. Among shrimp farmers, crop diversification has the relatively strongest significant positive effect on dietary diversity, suggesting part of the aquacultural crops are geared towards subsistence. By contrast, crop diversification seems to have a negative effect on dietary diversity among households that do not produce shrimp, especially when different agricultural crops are combined. Importantly, both for shrimp and non-shrimp farmers, crop diversification systems combining agriculture with aquaculture, and agroforestry seem to improve diverse diets among households. While by no means a panacea to solving FNS challenges among rural households, we suggest that promoting specific crop diversification systems could be a beneficial pathway to improved FNS outcomes.

Influence of agriculture on child nutrition through child feeding practices in India: A district-level analysis

Malnutrition continues to be a primary concern for researchers and policymakers in India. There is limited scientific research on the effect of agriculture on child nutrition in the country using a large representative sample. To the best of our knowledge, no study has examined the spatial clustering of child malnutrition and its linkage with agricultural production at the district-level in the country. The present study aims to examine agricultural production's role in improving the nutritional status of Indian children through child feeding practices. The nutritional indicators of children from the National Family Health Survey-4 (2015-16) and the agricultural production data for all the 640 districts of India obtained from the District-Wise Crop Production Statistics (2015-16), published by the Ministry of Agriculture, Government of India were used for the analysis. The statistical analysis was undertaken in STATA (version 14.1). ArcMap (version 10.3), and GeoDa (version 1.8) were used for the spatial analysis. The study found a higher prevalence of malnutrition among children who had not received Minimum Meal Frequency (MMF), Minimum Dietary Diversity (MDD), and Minimum Acceptable Diet (MAD). Further, child feeding practices- MMF, MDD, and MAD- were positively associated with high yield rates of spices and cereals. The yield rate of cash crops, on the contrary, harmed child feeding practices. Production of pulses had a significant positive effect on MDD and MAD. Districts with high cereal yield rates ensured that children receive MMF and MAD. There is a significant spatial association between child feeding practices and malnutrition across Indian districts. The study suggests that adopting nutrient-sensitive agriculture may be the best approach to improving children's nutritional status.

The Role of Land Ownership and Non-Farm Livelihoods on Household Food and Nutrition Security in Rural India

South Asia remains the region with the highest prevalence of undernourishment with India accounting for 255 million food insecure people. A worsening of child nutritional outcomes has been observed in many Indian states recently and children in rural areas have poorer nutrition compared to those in urban areas. This paper investigates the relationship between land ownership, non-farm livelihoods, food security, and child nutrition in rural India, using the Young Lives Survey. The survey covers the same rural households and children over the period 2002–2013 in the states of Andhra Pradesh and Telangana. Our empirical analysis uses a sample of 1209 children (and their households) who were aged around 1 year in 2002. Our results show that large agricultural land ownership is significantly associated with better child nutrition (measured using height-for-age and stunting) and household food security. A transition from farm to non-farm work improves child nutrition, but only among landless households. While access to land is still critical for improving household food and nutrition security among rural households, there is a trend towards greater non-farm livelihoods, and a decline in reliance on farming, particularly among landless and marginal farmers.

Equity in agriculture-nutrition-health research: a scoping review

Links among agriculture, nutrition, and health (ANH) are established, but the role of inequity is less understood. In this scoping review, we aimed to understand the range of ways that ANH research addresses inequity issues in low- and middle-income countries. We used PRISMA guidelines to structure our study. From an initial >26 000 studies, 243 published reports met inclusion criteria and were mapped. The number of reports addressing inequity in ANH research has increased over time from < 10 articles in 2008 to > 40 in 2018. Within equity, a majority of articles (n = 327) focused on describing how nutrition and health outcomes differ for different groups. Many (n = 134) looked at the material circumstances that shape people's life chances. Fewer (n = 51) looked at the most basic structural determinants of (in)equity. The same aspects of equity remain the least studied in ANH research, including the intersections of equity issues shaping life chances, and inequity's structural determinants. We suggest ways forward for this community, drawing on conceptual frameworks and theory of inequity from different disciplines.

Designing for empowerment impact in agricultural development projects: Experimental evidence from the Agriculture, Nutrition, and Gender Linkages (ANGeL) project in Bangladesh

The importance of women's roles for nutrition-sensitive agricultural projects is increasingly recognized, yet little is known about whether such projects improve women's empowerment and gender equality. We study the Agriculture, Nutrition, and Gender Linkages (ANGeL) pilot project, which was implemented as a cluster-randomized controlled trial by the Government of Bangladesh. The project's treatment arms included agricultural training, nutrition behavior change communication (BCC), and gender sensitization trainings delivered to husbands and wives together - with these components combined additively, such that the impact of gender sensitization could be distinguished from that of agriculture and nutrition trainings. Empowerment was measured using the internationally-validated project-level Women's Empowerment in Agriculture Index (pro-WEAI), and attitudes regarding gender roles were elicited from both men and women, to explore potentially gender-transformative impacts. Our study finds that ANGeL increased both women's and men's empowerment, raised the prevalence of households achieving gender parity, and led to small improvements in the gender attitudes of both women and men. We find significant increases in women's empowerment scores and empowerment status from all treatment arms but with no significant differences across these. We find no evidence of unintended impacts on workloads and inconclusive evidence around impacts on intimate partner violence. Our results also suggest some potential benefits of bundling nutrition and gender components with an agricultural development intervention; however, many of these benefits seem to be driven by bundling nutrition with agriculture. While we cannot assess the extent to which including men and women within the same treatment arms contributed to our results, it is plausible that the positive impacts of all treatment arms on women's empowerment outcomes may have arisen from implementation modalities that provided information to both husbands and wives when they were together. The role of engaging men and women jointly in interventions is a promising area for future research.

Do agri-food market incentives improve food security and nutrition indicators? a microsimulation evaluation for Kenya

The sustainable development goal #2 aims at ending hunger and malnutrition by 2030. Given the numbers of food insecure and malnourished people on the rise, the heterogeneity of nutritional statuses and needs, and the even worse context of COVID-19 pandemic, this has become an urgent challenge for food-related policies. This paper provides a comprehensive microsimulation approach to evaluate economic policies on food access, sufficiency (energy) and adequacy (protein, fat, carbohydrate) at household level. The improvement in market access conditions in Kenya is simulated as an application case of this method, using original insights from households’ surveys and biochemical and nutritional information by food item. Simulation’s results suggest that improving market access increases food purchasing power overall the country, with a pro-poor impact in rural areas. The daily energy consumption per capita and macronutrients intakes per capita increase at the national level, being the households with at least one stunted child under 5 years old, and poor households living areas outside Mombasa and Nairobi, those which benefit the most. The developed method and its Kenya's application contribute to the discussion on how to evaluate nutrition-sensitive policies, and how to cover most households suffering food insecurity and nutrition deficiencies in any given country.

Understanding Pathways Between Agriculture, Food Systems, and Nutrition: An Evidence and Gap Map of Research Tools, Metrics, and Methods in the Last 10 Years

New tools, metrics, and methods in agriculture, food systems, and nutrition (A&N) research proliferated in the decade following the 2007-2008 food price crisis. We map these developments across themes derived from conceptual A&N pathways and expert consultations. We created an interactive Evidence and Gap Map (EGM) from a systematic search of published and gray literature since 2008, following Campbell Collaboration guidelines. We retrieved over 30,000 reports from published literature databases, and individually searched 20 online repositories. We systematically screened 24,359 reports by title and/or abstract, 1577 by full report, and included 904 eligible reports. The EGM consists of rows of thematic domains and columns of types of tools, metrics, and methods, as well as extensive coding applied as filters. Each cell of the map represents research surrounding a type of tool, metric, or method within a given theme. Reports in each cell are grouped by stage of development, which expand to a corresponding bibliography. Users can filter EGM reports by various characteristics. The 4 most populated domains were: diets, nutrition, and health; primary food production; water, sanitation, and hygiene; and environment and sustainability. The 4 most common types of metrics, methods, and tools were: diet metrics; footprint analysis (especially water); technology applications; and network or Bayesian analysis. Gaps represent areas of few or no reports of innovation between 2008 and 2018. There were gaps in reports and innovations related to: power or conflicts of interest; food environments; markets; private sector engagement; food loss and waste; conflict; study design and system-level tools, metrics, and methods. The EGM is a comprehensive tool to navigate advances in measurement in A&N research: to highlight trends and gaps, conduct further synthesis and development, and prioritize the agenda for future work. This narrative synthesis accompanies the EGM, which can be found at https://www.anh-academy.org/evidence-and-gap-map.

How to design a complex behaviour change intervention: experiences from a nutrition-sensitive agriculture trial in rural India

Many public health interventions aim to promote healthful behaviours, with varying degrees of success. With a lack of existing empirical evidence on the optimal number or combination of behaviours to promote to achieve a given health outcome, a key challenge in intervention design lies in deciding what behaviours to prioritise, and how best to promote them. We describe how key behaviours were selected and promoted within a multisectoral nutrition-sensitive agriculture intervention that aimed to address maternal and child undernutrition in rural India. First, we formulated a Theory of Change, which outlined our hypothesised impact pathways. To do this, we used the following inputs: existing conceptual frameworks, published empirical evidence, a feasibility study, formative research and the intervention team’s local knowledge. Then, we selected specific behaviours to address within each impact pathway, based on our formative research, behaviour change models, local knowledge and community feedback. As the intervention progressed, we mapped each of the behaviours against our impact pathways and the transtheoretical model of behaviour change, to monitor the balance of behaviours across pathways and along stages of behaviour change. By collectively agreeing on definitions of complex concepts and hypothesised impact pathways, implementing partners were able to communicate clearly between each other and with intervention participants. Our intervention was iteratively informed by continuous review, by monitoring implementation against targets and by integrating community feedback. Impact and process evaluations will reveal whether these approaches are effective for improving maternal and child nutrition, and what the effects are on each hypothesised impact pathway.

Association of Livestock Ownership and Household Dietary Quality: Results from a Cross-Sectional Survey from Rural India

Studies from India and several eastern African countries found that the impact of dairy animal ownership on household nutrition varied greatly, depending on the socio-geographic context. The purpose of this study was to examine the association between livestock ownership and household dietary quality in rural Kolar district, India. We collected data from a household survey in four study villages (n = all 195 households of the four villages) of Kolar district, applying a cross-sectional design. Kendall's rank correlation coefficient was employed to determine the correlation between milk consumption and other dietary variables. Multivariable logistic regression was used to describe the relationship between dairy animal ownership and household milk consumption. Households owning dairy animals more often had access to irrigation (58.3% vs. 25.2%) and were less often woman-headed (2.4% vs. 22.5%). Household milk consumption was significantly correlated with consumption of vegetable variety, egg, and meat (all p-values < 0.05). After adjusting for multiple confounders, the odds ratio of milk consumption between dairy animal-owning households as compared to other households was 2.11 (95% confidence interval 0.85, 5.45). While dairy animal ownership was found to be associated with improved dietary quality, larger households were in a better position to adopt dairy animals, which, in turn, might contribute to better household nutrition.

Tracing the Single and Combined Contributions of Home-Grown Supply and Health Literacy on Fruit and Vegetable Consumption: An Empirical Exploration in Rural India

Low fruit and vegetable consumption (FVC) remains a global health challenge. Fostering subsistence agriculture through the production and home-grown consumption (HGC) of fruits and vegetables are seen as potential strategies for improving overall FVC, in particular, for developing countries like India. In addition, educational strategies targeting FVC health literacy are also used. Little evidence has documented a connection between these two strategies. We examine the single and combined influence of HGC and health literacy with regard to benefits from fruits and vegetable consumption. Data were collected from 427 rural households in the state of Odisha, India. Three outcomes were examined: FVC, as well as fruit and vegetables separately. Linear and Poisson regression were used to examine the association among home-grown consumption (HGC), FVC health literacy, and the FVC outcomes. Findings show that HGC, but not FVC health literacy, was directly associated with FVC (β = 0.65, SE = 0.10, p = 0.008) and vegetable consumption (β = 0.57, SE = 0.11, p = 0.02). However, both HGC (β = 0.58, SE = 0.05, p < 0.01) and FVC health literacy (β = -0.07, SE = 0.02, p = 0.001) were associated with fruit consumption. In addition, HGC effect is concentrated among participants who reported low FVC health literacy, especially on overall FVC and vegetables alone. Results are discussed in relation to the beneficial role played by HGC in those particularly vulnerable households who perceived little FVC health literacy. Our results provide insights on novel improved FVC consumption across all population segments. Future research should explore the complex interplay between agricultural policies and educational programs in the design of interventions promoting fruit and vegetable production and consumption.

Women's empowerment and their experience to food security in rural Bangladesh

Global discourses have advocated women's empowerment as a means to reduce their own's food insecurity, which is also key development challenges in Bangladesh. However, little empirical research has conducted on this issue, especially in the rural area of Bangladesh. Therefore, the present study was conducted to examine the relationship of six domains of women's empowerment with their food security in rural Bangladesh using a partial least square structural equation modelling approach. Our empirical analysis indicates that women's accesses to their legal and familial rights and decision-making roles in households increase their bargaining power over the utilization of resources and to choices of food which significantly and negatively decrease their food insecurity. Moreover, information and communication technologies and infrastructure facilities also negatively and significantly associated with women's food insecurity. However, women's leadership has a negative but not significant effect on their food insecurity, as low self-esteem rural women feel no ease in publicly addressing their inequalities. By understanding family composition from women's perceptions, the results from our research can assist policymakers to develop more suitable strategies to enhance the empowerment status of rural women and reduce their food insecurity.

Seasonal time trade-offs and nutrition outcomes for women in agriculture: Evidence from rural India

Women in agriculture are involved in agricultural activities and are solely responsible for household-level unpaid work. They face severe time trade-offs between agricultural and household activities across crop seasons. Recent literature suggests that these time trade-offs may negatively impact their nutrition. However, there is no quantitative evidence exploring this relationship within an agricultural context. This paper addresses this research gap by analyzing the relationship between women's time trade-offs and their nutritional outcomes. Using a unique ten-month primary panel data of 960 women from India, our findings show that women are severely time-constrained, as they contribute significantly to agricultural as well as domestic work. Our results show that during peak seasons relative to lean seasons, women's time trade-offs (rising opportunity cost of time) are negatively associated with the intake of calories, proteins, iron,zinc and Vitamin A. We show that this negative relationship is manifested severely among women who are landless and cultivate paddy alone (food crop) or paddy and cotton (mixed crop). This study highlights the gendered role of agricultural activities in rural households and the need to recognize time as a scarce resource when implementing policies and programs involving women in agriculture. We contribute to the literature of agriculture-nutrition linkages by examining the the time use pathway in detail. Besides providing novel metrics, we discuss several policy implications to reduce women's time constraints and enhance their nutrition.

Seasonal trends and maternal characteristics as predictors of maternal undernutrition and low birthweight in Eastern Maharashtra, India

Few studies have assessed whether women and infants in rural and peri-urban communities in South Asia experience seasonal fluctuations in nutritional status; however, a handful of studies have documented seasonal variability in risk factors for undernutrition including food availability, physical activity and infections. We used data from the Maternal and Newborn Health (MNH) registry, a population-based pregnancy and birth registry in Eastern Maharashtra, India, to analyse seasonal trends in birthweight and maternal nutritional status-body mass index (BMI) and haemoglobin-in the first trimester of pregnancy. We plotted monthly and seasonal trends in birthweight, and maternal BMI and haemoglobin, and used multivariable regression models to identify seasonal and maternal characteristics that predicted each outcome. Between October 2014 and January 2018, MNH included 29,253 livebirths with recorded birthweight. BMI was assessed in 15,252 women less than 12 weeks of gestation and haemoglobin in 18,278 women less than 13 weeks of gestation. Maternal characteristics (age, education, parity and height) were significantly associated with nutritional status; however, there were minimal seasonal fluctuations in birthweight or maternal nutrition. There were significant secular trends in maternal haemoglobin; between 2014 and 2018, the prevalence of maternal anaemia decreased from 91% to 79% and moderate or severe anaemia from 53% to 37%. The prevalence of maternal underweight (45.3%) and overweight (9.8%) and low birthweight (19.1%) remained relatively constant over the study period. Our findings highlight that in some rural and peri-urban areas in South Asia, tackling systemic drivers of malnutrition may be more effective than targeted interventions based on season.