When women eat last: Discrimination at home and women's mental health

The role of community-level men's and women's inequitable gender norms on women's empowerment in India: A multilevel analysis using India's National Family Health Survey-5

BACKGROUND

Lower empowerment of women is a critical social issue with adverse public health implications. In India, deeply ingrained gender norms shape a patriarchal structure that creates systemic disadvantages for women relative to men. These gender norms-socially constructed expectations about the roles, behaviors, and attributes of men and women-perpetuate inequality and limit women's opportunities.

OBJECTIVES

The aim of this study was to examine the association between community-level men's and women's gender norms on women's empowerment in India. Women's empowerment was defined using four measures: freedom of movement, decision-making power, economic empowerment, and health empowerment.

METHODS

Using a nationally representative demographic health survey data from 2019-21 of 63,112 married women who participated in the women's empowerment module and 101,839 men surveyed, we constructed community-level men's and women's inequitable gender norms variables as our independent variable using attitudes towards wife-beating questions. We used random effects logistic regression models to examine if community-level men's and women's inequitable gender norms were independently associated with the different dimensions of women's empowerment.

RESULTS

One standard deviation increase in community-level men's and women's inequitable gender norms was associated with reduced odds of freedom of movement, decision-making power, and health empowerment. No statistically significant association was observed between community-level men's and women's gender norms and economic empowerment.

CONCLUSION

Inequitable gender norms are a risk factor that is negatively associated with several dimensions of women's empowerment. Our findings support our hypotheses that women's empowerment is impacted separately by men's and women's gender norms. Our study underscores the pressing need for concerted efforts to challenge and transform inequitable gender norms, paving the way for achieving gender equality and women's empowerment, as envisioned by the Sustainable Development Goals.

The Relationship between Family Functioning, Emotional Intelligence, Loneliness, Social Support, and Depressive Symptoms among Undergraduate Students

The transition from adolescence to college is a significant developmental stage marked by challenges such as high academic pressure, changes in living environments, and social support systems. These challenges can lead to increased rates of depression among college students. This study investigates the relationships between family functioning, emotional intelligence, loneliness, social support, and depressive symptoms in Chinese college students. A cross-sectional design was employed, with data collected via questionnaires from undergraduate students at Xi'an Jiaotong University. Variables such as family functioning, emotional intelligence, loneliness, social support, and depressive symptoms were assessed. Statistical analyses, including correlation and hierarchical regression, were conducted to explore these relationships. The study found a diverse distribution of depressive symptoms among students, with significant gender differences indicating higher depression rates in females. No significant differences were observed across academic disciplines, grades, or between only children and non-only children. Family functioning, emotional intelligence, and social support were negatively correlated with depressive symptoms, while loneliness was positively correlated. Hierarchical regression analysis confirmed that social support significantly moderated the relationship between family functioning and depressive symptoms. Mediation analysis showed that emotional intelligence and loneliness mediated this relationship. The findings highlight the complex interplay between family dynamics, emotional capabilities, social connectedness, and mental health. Enhancing family functioning, emotional intelligence, and social support can effectively reduce depressive symptoms among college students. These results underscore the need for holistic interventions that address multiple aspects of students' social and emotional lives.

The great Indian demonetization and gender gap in health outcomes: Evidence from two Indian states

We utilize the timing of India's 2016 demonetization policy to examine whether a negative macroeconomic shock disproportionately affects women's health outcomes relative to men's. Our empirical framework considers women as the treated group and men as the comparison group. Using data from the National Family Health Survey-4 and a household fixed effects model, we find that the induced income shock leads to a 4% decline in hemoglobin for women as compared to the pre-demonetization level. This corresponds to a 21% increase in the gender gap in hemoglobin. The result is further validated with an event study and a variety of robustness checks. An examination of food consumption suggests that this pattern is possibly driven by a widening male-female gap in the consumption of iron-rich foods.

Who eats last? Intra-household gender inequality in food allocation among children in educationally backward areas of India

The practice of women eating after men is a common gender-inequitable food allocation mechanism among adults in Indian households and has been associated with poor health and nutritional outcomes for women. However, empirical evidence on whether a similar practice of girls eating after boys is prevalent among children is scarce. Using primary data from a household survey conducted in educationally backward areas of four Indian states, we provide new evidence of this practice among children. Almost 28 per cent of the sample households follow the mealtime custom of girls eating after boys. Scheduled Tribes and households with higher incomes are less likely to follow this practice. Other relevant factors include children's relative ages by sex and an interplay between family size and children's sex composition. While our findings may not be generalizable, they suggest an intersectionality between gender and other dimensions of inequality, namely social identity and economic class.

Sex and gender in health research: intersectionality matters

Research policies aiming to integrate sex and gender in scientific studies are receiving increased attention in academia. Incorporating these policies into health research is essential for improving targeted and equitable healthcare outcomes, by considering both disparities and similarities between individuals relating to sex and gender. Although these efforts are both urgent and critical, only an intersectional approach, which considers broad and multidimensional aspects of an individual's identity, can provide a complete understanding of the factors that impact health. In this commentary, we emphasize that it is crucial to examine how sex and gender intersect with factors such as culture, ethnicity, minority status, and socioeconomic conditions to influence health outcomes. To approach health equity, we must consider disparities linked to both biological and environmental factors, in order to facilitate evidence-based health interventions with tangible impact.

Does Childhood Experience of Interparental Abuse Shape Women's Attitude Toward Intimate Partner Violence in Their Adult Life? Evidence From 31 Developing Countries

A significant amount of literature exists on the lasting effects of interparental abuse on children's psychological health as adults. However, evidence on how children's childhood experience of interparental violence shapes their attitude toward partner violence in adult intimate relationships is limited. Given the existing evidence that women's acceptance of partner violence as a social norm increases the risk of partner violence, we analyzed the effect of girls' witnessing interparental abuse (where a father is a perpetrator) on their attitude toward partner violence in their intimate relationships as adults. We used data from the Demographic and Health Surveys for 31 low and middle-income countries in Asia and Africa. Aggregating information about women's attitudes toward partner violence into a binary "intimate partner violence acceptance" variable, we found that a woman who witnessed her father beat her mother was 1.62 times more likely to justify partner violence than a woman who did not experience such interparental abuse (adjusted odds ratio [AOR] = 1.62, 95% CI [1.57, 1.66], p < .001). Additionally, using individual components of acceptance as response variables, we found that a woman who witnessed interparental abuse was significantly more likely to justify partner violence if she went out without telling her husband (OR = 1.49, 95% CI [1.45, 1.54], p < .001), neglected children (OR = 1.53, 95% CI [1.49, 1.58], p < .001), argued with the husband (OR = 1.49, 95% CI [1.45, 1.53], p < .001), refused sex with the husband (OR = 1.35, 95% CI [1.31, 1.39], p < .001), or burned food (OR = 1.36, 95% CI [1.31, 1.41], p < .001). This study highlights the need to put in place children-specific social policies to limit the intergenerational transmission of the adverse effects of intimate partner violence.

Facilitating behavioral change: A comparative assessment of ASHA efficacy in rural Bihar

Community health worker (CHW) programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors. One of these programs, called Accredited Social Health Activists (ASHA), was initiated by the government of India in 2005 and now has a workforce of about 1 million. ASHAs primarily focus on improving maternal and child health but also support other health initiatives. Evaluations of ASHA efficacy have found a range of results, from negative, to mixed, to positive. Clarity in forming a general impression of ASHA efficacy is hindered by the use of a wide range of evaluation criteria across studies, a lack of comparison to other sources of behavioral influence, and a focus on a small number of behaviors per study. We analyze survey data for 1,166 mothers from Bihar, India, to assess the influence of ASHAs and eight other health influencers on the uptake of 12 perinatal health behaviors. We find that ASHAs are highly effective at increasing the probability that women self-report having practiced biomedically-recommended behaviors. The ASHA's overall positive effect is larger than any of the nine health influencer categories in our study (covering public, private, and community sources), but their reach needs to be more widely extended to mothers who lack sufficient contact with ASHAs. We conclude that interactions between ASHAs and mothers positively impact the uptake of recommended perinatal health behaviors. ASHA training and program evaluation need to distinguish between individual-level and program-level factors in seeking ways to remove barriers that affect the reach of ASHA services.

Do changes in women's household status in Nepal improve access to food and nutrition?

Women's nutritional status remains poor in South Asia, impacting maternal and infant health outcomes. Women's household status is also low, as evidenced by eating behaviours. We started with triadic qualitative interviews with newly married women, husbands and mothers-in-law to explore the link between women's status and eating patterns, followed by longitudinal data from a cohort of 200 newly married women in rural Nepal to measure associations over time. Quantitative data were collected every 6 months for 18 months (four rounds of data) between 2018 and 2020. Interviews suggested that household relationships, women's status, and how much and what types of food she was given were intricately linked. Using mixed effects logistic regression models, we explore the association between markers of changing women's status (becoming pregnant, giving birth and working outside the home) on two outcomes (eating last always/usually and achieving minimum dietary diversity). We also explore for interaction between women's status and household food insecurity. Pregnancy increases women's dietary diversity, but this is not sustained post-partum. Women who work outside the home are less likely to eat last in the household. Food insecurity is associated with both the order of household eating and dietary diversity. Interactions between food insecurity and giving birth suggested that women who give birth in food insecure households are more likely to eat last in the household. Changes in women's household status are associated with some improvements in dietary diversity and order of household eating, but the associations are not long-lasting and depend on food security status.

Women's well-being during a pandemic and its containment

The COVID-19 pandemic brought the dual crises of disease and the containment policies designed to mitigate it. Yet, there is little evidence on the impacts of these policies on women in lower-income countries, where there may be limited social safety nets to absorb these shocks. We conduct a large phone survey and leverage India's geographically varied containment policies to estimate the association between the pandemic and containment policies and measures of women's well-being, including mental health and food security. On aggregate, the pandemic resulted in dramatic income losses, increases in food insecurity, and declines in female mental health. While potentially crucial to stem the spread of COVID-19, the greater prevalence of containment policies is associated with increased food insecurity, particularly for women, and reduced female mental health. For surveyed women, moving from zero to average containment levels is associated with a 38% increase in the likelihood of reporting more depression, a 73% increase in reporting more exhaustion, and a 44% increase in reporting more anxiety. Women whose social position may make them more vulnerable - those with daughters and those living in female-headed households - experience even larger declines in mental health.

Nutritional Status and Intra-household Food Distribution Among Reproductive-Age-Group Women in a Slum Area of Hooghly District, West Bengal: A Mixed-Methods Approach

Introduction

Malnutrition among women of reproductive age (WRA), especially those living in slum areas, is one of the most concerning nutritional issues because of the extreme nutritional stress they face in the form of inequitable intra-household food distribution (IHFD). This study aimed to assess the nutritional status (NS) and its association with IHFD among reproductive-age-group women along with exploring the perspectives of the stakeholders regarding inequitable food distribution.

Materials and methods

The quantitative part of the convergent parallel mixed-methods design study was conducted among 150 WRA, selected by cluster random sampling from 15 slum areas of Hooghly District, between December 2020 and May 2021. Data were collected using a predesigned pretested schedule with anthropometric measurements. IHFD was quantified by the relative dietary energy adequacy ratio (RDEAR). Ordinal logistic regression was performed to obtain adjusted-proportional odds ratios (aPOR) for higher categories of NS (underweight: reference category). Stratified subgroup analysis was done to assess the influencers of IHFD. For the qualitative part, in-depth interviews were conducted with eight purposively selected in-laws of study participants, and the data were interpreted by thematic analysis.

Results

The mean age of the study participants was 28.6±6.3 years. The proportion of malnutrition and inequitable IHFD (RDEAR<1) among them was 50% and 46%, respectively. Higher categories of NS were found to be significantly associated with an increase in RDEAR (aPOR=22.6, 95% CI: 2.75-185.45, p-value=0.004). Among underweight and normal NS women, those who were earning members and directly involved in food preparation/production had a greater allocation of food within their households. Physiological intolerance, incapacity of earning, and traditional customs were the most recurring themes transcribed as the barriers to equitable food distribution.

Conclusion

A high magnitude of malnutrition and its association with inequitable IHFD among WRA warrant policy-level support to increase women's employment opportunities and address gender-based inequities through comprehensive information education communication (IEC) techniques as well.

The development and feasibility of a group-based household-level intervention to improve preconception nutrition in Nawalparasi district of Nepal

BACKGROUND

In a setting such as Nepal with malnutrition and persistent poor maternal and infant health outcomes, developing interventions to improve the nutrition of preconception and pregnant women is essential.

OBJECTIVE

The objectives of this paper are to describe the full design process of an intervention for newly married women, their husbands, and mothers-in-law to improve maternal nutrition and gender norms, and findings from the feasibility and acceptability pilot.

METHODS

In this paper we describe the three phases of the design of an intervention in rural Nepal. We first conducted a mixed methods formative phase which included in depth interviews with newly married women, their husbands and mothers-in-law (N=60) and a longitudinal study for 18 months with 200 newly married women. We then designed of a household level, group, intervention, in close partnership with community members. Finally, we conducted a pilot intervention with 90 participants and collected both pre/post survey data and in-depth qualitative interviews with a subset (N= 30). All participants from all phases of the study lived in Nawalparasi district of Nepal. Qualitative data was analyzed using a thematic analysis, with inductive and deductive themes and quantitative data was analyzed using descriptive statistics.

RESULTS

Our formative work highlighted lack of awareness about nutrition, and how women eating last, limited mobility, household and community inequitable gender norms and poor household-level communication contributed to low quality diets. Thus we designed Sumadhur, an intervention that brought groups of households (newly married wife, husband, and mother-in-law) together weekly for four months to strengthen relationships and gain knowledge through interactive content. We found Sumadhur to be highly feasible and acceptable by all respondents, with most (83%) attending 80% of sessions or more and 99% reporting that they would like it to continue. Pre/post surveys showed a decrease in the proportion of women eating last and increase in knowledge about nutrition in preconception and pregnancy. Qualitative interviews suggested that respondents felt it made large impacts on their lives, in terms of strengthening relationships and trust, understanding each other, and changing behaviors.

CONCLUSIONS

We show how a designing an intervention in close partnership with the target recipients and local stakeholders can lead to an intervention that is able to target complicated and culturally held practices and beliefs, positively benefit health and wellbeing, and that is very well received.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04383847 , registered 05/12/2020.

Perceived discrimination and health outcomes among middle-aged and older adults in India: results of a national survey in 2017-2018

BACKGROUND

The study aimed to estimate the associations between perceived discrimination and poor physical health, poor mental health, and health risk behaviours in middle-aged and older adults in a national population survey in India.

METHODS

The sample included 72,262 middle-aged and older adults from a cross-sectional national community dwelling survey in India in 2017-2018.

RESULTS

The prevalence of moderate (1-2 types) perceived discrimination was 10.7%, and high (3-6 types) perceived discrimination was 6.6%. In the final adjusted logistic, linear or Poisson regression analyses, moderate and/or high perceived discrimination was significantly positively associated with poor mental health (low life satisfaction, poor cognitive functioning, insomnia symptoms, and depressive symptoms), poor physical health (pain conditions count, and functional limitations), and health risk behaviours (heavy episodic drinking and physical inactivity).

CONCLUSION

Perceived discrimination is associated with poor mental health, poor physical health, and health risk behaviour, emphasising the need to consider perceived discrimination in various physical and mental health contexts.

Measurement of population mental health: evidence from a mobile phone survey in India

In high-income countries, population health surveys often measure mental health. This is less common in low- and middle-income countries (LMICs), including in India, where mental health is under-researched relative to its disease burden. The objective of this study is to assess the performance of two questionnaires for measuring population mental health in a mobile phone survey. We adapt the Kessler-6 screening questionnaire and the World Health Organization's Self-Reporting Questionnaire (SRQ) for a mobile phone survey in the Indian states of Bihar, Jharkhand and Maharashtra. The questionnaires differ in the symptoms they measure and in the number of response options offered. Questionnaires are randomly assigned to respondents. We consider a questionnaire to perform well if it identifies geographic and demographic disparities in mental health that are consistent with the literature and does not suffer from selective non-response. Both questionnaires measured less mental distress in Maharashtra than in Bihar and Jharkhand, which is consistent with Maharashtra's higher human development indicators. The adapted SRQ, but not the adapted Kessler-6, identified women as having worse mental health than men in all three states. Conclusions about population mental health based on the adapted Kessler-6 are likely to be influenced by low response rates (about 82% across the three samples). Respondents were different from non-respondents: non-respondents were less educated and more likely to be female. The SRQ's higher response rate (about 94% across the three states) may reflect the fact that it was developed for use in LMICs and that it focuses on physical, rather than emotional, symptoms, which may be less stigmatized.