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Value Chains for Nutrition in Rural India
Investigating barriers to fruit and vegetable consumption among women of reproductive age
Sarah [email protected]
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Overview• Introduction to the work at MRC• Public health challenges in India• Description of previous longitudinal research in
India that led to LANSA-funded ‘Value chains for nutrition’ study
• Value chains for nutrition study• Future plans
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MRC Lifecourse Epidemiology Unit
http://www.mrc.soton.ac.uk
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MRC Lifecourse Epidemiology Unit
http://www.mrc.soton.ac.uk
5
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India UKPopulation 1.22 bn 63.7m% Living in rural areas 70 20Population density per km2 373 255Gross National Income per capita (US$/ year)
1,410 37,780
Human Development Index Score* 0.547 0.863Human Development Index Ranking * 134/187 28/187Gender Inequality Index Ranking* 129/146 34/146
*United Nations Development Programme data
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Indian Population between 1950 and 2100 by age groups and sex (absolute numbers in millions)
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2015 Global Hunger Index South, East and SE Asia
Source: International Food Policy Research Institute. http://ghi.ifpri.org/
CountryProportion of
undernourished in population (%)
Prevalence of wasting in children <5 years (%)
Prevalence of stunting in children <5 years (%)
Under five mortality rate
(%)
Score
Timor-Leste
26.9 18.9 57.7 5.5 40.7
Afghanistan
26.8 9.5 40.9 9.7 35.4
Pakistan 22 10.5 45 8.6 33.9
India 15.2 15 38.8 5.3 29
North Korea
41.6 4 27.9 2.7 28.8
Lao PDR 18.5 6.4 43.8 7.1 28.5
Bangladesh
16.4 14.3 36.1 4.1 27.3
Sri Lanka 22 21.4 14.7 1 25.5
Myanmar 14.2 7.9 35.1 5.1 23.5
Cambodia 14.2 9.6 32.4 3.8 22.6
Nepal 7.8 11.3 37.4 4 22.2
Indonesia 7.6 13.5 36.4 2.9 22.1
Philippines 13.5 7.9 30.3 3 20.1
Mongolia 20.5 1 10.8 3.2 14.7
Vietnam 11 5.7 19.4 2.4 14.7
Thailand 7.4 6.7 16.3 1.3 11.9
Malaysia 2* 10.7* 11.2* 0.9 10.3
Fiji 4.5* 6.6* 3.7* 2.4 8.7
China 9.3 2.3 9.4 1.3 8.6
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Mapping of BMI of Indian women aged 15-49 by state (2005-6)
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Age standardised prevalence of raised fasting blood glucose by country in 2008
Source: WHO Global Health Observatory. Raised blood glucose is defined as ≥7.0mmol/L or being on medication for raised blood glucose ages ≥25years
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Global burden of low birth weight and diabetes
Type 2 Diabetes
LBW
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Approximately 2 billion people globally are micronutrient deficient with women of reproductive age disproportionately affected.
(Black et al, Lancet 2008;371:243-60 & Ramakrishnan, Nutr Rev 2002;60:S46-S52)
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Pune Maternal Nutrition Study• Observational data from villages outside Pune, India showed
that intakes of green leafy vegetables, fruit and milk were positively associated with birth size.
2.5
2.6
2.7
2.8
Never <1/wk
1/wk >3/wkGreen leafy vegetables intake @ 28 wks
p<0.001
Source: Rao. J Nutr 2001;131:1217-1224
Birth weight
(kg)
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Mumbai Maternal Nutrition Project
• Randomised controlled trial of a food-based supplement.
• Primary outcomes: birth size and infant mortality.
• Participants were married women of reproductive age, living in Mumbai slums and intending to have children.
• The supplement was consumed daily for at least 3 months pre-conceptionally and throughout pregnancy.
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Bir
th w
eigh
t (g
)
ALL WOMEN
CONTROL
TREATMENT
Mother’s pre-pregnant BMI (kg/m2)
<18.6 18.6-21.8
>21.8
+ 48g - 8g + 79g + 113g
Mean and 95% confidence intervals
p value for interaction: p=0.001
2350
2400
2450
2500
2550
2600
2650
2700
2750
2800
2850
0
Potdar R et al. AJCN 2014; 100: 1257-68Sahariah S et al. J Nutr 2016 (in press)
Gestational diabetes:Treatment: 7.3%Control: 12.4%OR (95%CI) 0.56 (0.36, 0.86)
Mumbai Maternal Nutrition Project -Results
Fruit and Vegetable Intakes
UK popu-lation
India slum India rural0
0.51
1.52
2.53
3.54
4.55
Med
ian
port
ions
of f
ruit
an
d ve
geta
bles
/ da
y
Source: National Diet and Nutrition Survey, UK; National Family Health Survey-3, India
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To summarise…• Intakes of fruit and vegetables are low in rural
India.
• Increasing intakes may improve fetal growth and development thereby reducing risk of mortality in the short term and preventing chronic disease in the longer term.
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Why are fruit and vegetable intakes low in rural India?
What are the modifiable constraints to fruit and vegetable intakes?
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Determinants of Dietary Diversity“Variety of foods across and within food groups capable of ensuring adequate intakes of essential nutrients” (FAO/WHO 1996).
Diet diversity in rural East India was poor among:• Low educated• Low socio-economic status• Families with female head of households• Families with poor purchasing powerParappurathu et al, 2015. Food Security, 7(5); 1031-1042
Identifying nutrition-sensitive interventions to improve maternal diet quality in rural Indian settings using value chain analysis
Core Objectives
1. To undertake exploratory qualitative research to identify constraints and facilitators to consumption of fruit and vegetables in rural Maharashtra.
2. To map the value chains for selected exemplar foods.
3. To provide policy-relevant output regarding the incorporation of nutritional priorities into value chain activities.
Core Objectives
1.To undertake exploratory qualitative research to identify constraints and facilitators to consumption of fruit and vegetables in Maharashtra.
2. To map the value chains for selected exemplar foods.
3. To provide policy-relevant output regarding the incorporation of nutritional priorities into value chain activities.
Study Setting & Team
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Approach• Qualitative
• Exploratory
• Hypothesis generating
• Researcher aims to have no pre-conceptions when collecting data
Design And Methods• Workshops with Stakeholders in Mumbai and Wardha1) Research gaps; linking fruit and vegetable value chains with nutrition.2) Obtain perspectives of stakeholders on problems and potential solutions.3) Identify exemplar fruit and vegetable value chains to be studied in detail.
• Focus group discussions with women consumers.
• In depth interviews with value chain actors (farmers, wholesalers and vendors).
• Second set of stakeholder workshops to discuss findings and propose interventions.
Stakeholder Workshops• Mumbai Workshop AttendeesMaharashtra State Rural Livelihood MissionMahila Arthik Vikas Mahamandal (MAVIM)Indira Gandhi Institute of Development ResearchNational Institute of Nutrition• Constraints to fruit and vegetable intakes Time demands Gender Inequality Land use / cash crops Poverty Political will Difficulty linking agriculture with nutrition and health at the State levelImportance of understanding the problems from consumer’s point of view
Stakeholder Workshops• Wardha Workshop AttendeesMaharashtra State Rural Livelihood MissionZilla Parishad Representatives of Farmers’ Unions, Consumers, Farmers, Vendors
• Exemplar fruit and vegetable value chains to be studied using in depth interviews:
Mango Guava Spinach Bhindi
Focus Group Discussions• Women recruited
by ‘key persons’ in the villages.
• 8-10 women per group. Grouped by caste, age and land ownership.
• Audio-tape recorded, transcribed and translated to English.
Focus Group Discussions• 8 FGD conducted.• Total of 82 women.• Inductive thematic
analysis was used to identify emerging themes.
• Data collection stopped when no new themes emerged.
Identifying Key Themes
• Preliminary Findings
Household DynamicsWorkload Personal Factors Time Pressures Practical FactorsSocial and Cultural NormsCost
Household Dynamics
“Women do not get to eat proper meals the way they are supposed to. Men would get proper meal (laugh)”
“There is big family.. hence there is no question to take
any decision. Whatever [vegetables] we get we
prepare that”
Workload
“I get tired in the evenings. So do not have meal,
somehow gulp a morsel or two and go to bed”.
“We have to fetch water, wash utensils, get flour from the mill, go to field. That is
what woman has to do. After that only she gets to eat”
Personal Factors
“Fenugreek and spinach are the only two green
leafy vegetables I like ”
“My daughters are having (fruits), this is more than
enough. Not bothered about myself. I overcome my
craving”
Time Pressures
“I don’t like to keep pending work. I am ok if do not get food but I am happy if I finish all work within time.
“I don’t have full meal in the morning because I have to
rush to farm”
Practical Factors
“Whenever we go to Wardha we get it [fruit]. Every day we cannot have. We go Wardha once in one or two months”
“Those who have place may prepare kitchen garden at home.. can cultivate green vegetables. Those who do
not have place can not cultivate. They do not have
any other option than buying.”
Social and Cultural Norms
“Papaya is hot. [This] means in pregnancy if you have it then there is more chances of miscarriage. My grandmother said”
“How can he help me? If he helps me in household chore
then in village, everybody gossip about him or say bad
things”
Cost
“When there is the inflation that time, they
mostly invest their money in the farm and in the
house; hence they create thrifty condition in home”
“During summer, the vegetable which is 5 rupees per 250 grams becomes 20-25 rupees per 250 grams”
Next steps
• Analysing in-depth interviews with actors focusing on exemplar food value chains.
• Hold further stakeholder workshops to discuss our findings and develop ideas for interventions.
Challenges
• Developing relationships with State Agriculture and Marketing departments.
• Issue of context and how to make the outputs of the project relevant to different settings.
Acknowledgements
• Study participants• MSSRF Wardha gender team and administration
staff• Dr Rengalakshmi and colleagues, MSSRF Chennai• Aulo Gelli, IFPRI• Centre for Study of Social Change• Wendy Lawrence, Kumaran Kalyanaraman and Ilse
Bloom at MRC LEU
