In this toolkit, community members and relevant stakeholders at local level are central to the analyses of the nutrition, agriculture, gender and WASH situation. It is envisaged that the assessment process will enhance community knowledge and awareness of the food and nutrition situation and lead to a demand for improvement in programmes and policies in the four domains. The underlying assumption is that doing so will contribute to better outcomes of agricultural interventions. Better outcomes essentially mean improved nutrition for all community members (men, women, boys and girls) especially foetal as well as infant (0-24 months) nutrition and development. Improved nutrition will lead to better child development that will contribute to positive benefits during the course of life.
Four main pathways
In order to obtain improved nutrition for community members and optimal foetal and infant nutrition and development, four main pathways have evolved through which communities can influence their nutrition situation. Nutritional problems beyond clinical manifestations, such as stunting and wasting, are often not visible to the community. Likewise, gender relations that come in the way of addressing under-nutrition are also often invisible, more so because they are embedded in community norms and values. The toolkit assists communities to conduct their own problem analysis, and to make them aware of the nutritional issues that are not apparent to them. The probable interventions derived as an outcome of the various steps in the toolkit align with the four pathways explained below.
The first pathway towards improved nutrition is achieved through making visible the existing burden of diseases, such as diarrhoea and dysentery which, in this theory, relates to the domain of water, hygiene and sanitation (WASH). The hypothesis is that when community members, particularly children, have lower exposure to diseases, their requirement for nutrients goes down. In other words, as they do not have to fight diseases, their nutritional status is better. At the heart of this pathway is the realization that mere provision of safe drinking water, sanitation (toilets) and education does not guarantee â€˜sustained useâ€™. Communities first have to acknowledge that they have a high disease burden that is caused by unsafe water, poor hygiene and sanitation, and then be made aware that disease is preventable.
In many contexts, women are responsible for fetching water, and are also in-charge of preparing family meals. Nonetheless, providing women with the opportunity (time and resources) to get clean water is not sufficient; they also need to be able to make decisions about the use and management of these resources. This pathway is therefore also about making the community – men and women – aware of gender inequalities in labour division, access to clean water sources and decision-making within households, which may contribute to the high burden of diseases and poor WASH practices. This leads to the next pathway that is directed at making people aware of the potential to change roles and task division, create equitable access and decision-making, leading to better results for nutrition.
The second pathway towards improving nutrition is through creating awareness about and improving feeding and caregiving practices. Community members – young fathers, mothers and other care-givers – are often not aware that their caregiving practices are likely to contribute under-nutrition. Inadequate nutrition knowledge, and its impact on the health of the child and themselves, are direct causes of under-nutrition. Women â€“ mothers and grandmothers and/or older girls (siblings) – are traditionally the caregivers in households. Competing claims on the motherâ€™s time for cooking, cleaning, fetching water, feeding and taking care of children, and also engaging in farm work and other income generation activities, takes away valuable time from caregiving, especially for the younger children in the household. The latter are often left in the care of their siblings or grandmothers without provision for enough food for the day. Moreover, pregnant women seldom get opportunities for extra rest or to eat nutritious food. Fathers are often ignorant about nutrition and do not make informed decisions while buying food items. Secondly, even though women are (expected to play) the main caregivers, they do not have the freedom to make independent decisions. Therefore, targeting women alone in nutrition specific interventions is not enough or effective â€“ there is a need for simultaneously educating communities about how current division of feeding practices and caregiving roles and responsibilities need to change if the nutrition situation is to improve. The assessment process can help to identify positive examples of households that factor-in care and nutrition practices in role division, and use them as drivers for change to motivate other households. Facilitating a dialogue about these issues within the community and key stakeholders will lead to an awareness that can then be translated into action, and change roles and decision-making that influence care practices and parenting in a positive way.
The third pathway refers to food utilization i.e. preparation of nutritious meals and dietary diversity at household level. In order to prepare nutritious meals, first the food needs to be available in the household; then those who prepare the food (women), need the power to make decisions about food choices, how they prepare it and how to divide the food among household members. The food utilization pathway is also about understanding current customs and beliefs around the meaning of what constitutes nutritious foods. For example, there are several trends and misconceptions about the type of foods pregnant women can and cannot eat, that vary per context, which negatively affect the nutritional status of pregnant women. Community opinion leaders can be influential in promoting desired changes in behaviours and practices. They can be involved not only to demonstrate and reinforce positive examples but also to change perceptions regarding roles and responsibilities of different family members, particularly women with reference to local beliefs around pregnancy and caregiving practices.
The fourth pathway involves food availability and accessibility. For nutritious food to be available to households, these foods either have to be produced, or have to be available at affordable prices in local markets. In terms of food availability, in order for men and women to make informed decisions to grow nutritious food, they both need access to information, inputs and services. The same applies to food accessibility, where again both men and women ought to decide how much: a) household income is to be spent on food and non-food items; and b) food is to be sold and kept for home consumption. These decisions are directly influenced by the roles they are expected to perform. While designing interventions in the fourth pathway, it is important to examine the conditions in which certain food crops are grown â€“ What crops are being grown? How diverse is production? What production activities are supported by government programmes and policies? What inputs and advisory services are available and accessible to improve productivity, and to whom? Also, who decides what to produce? Who contributes labour to production? How are roles divided across men and women? Likewise examining the conditions in which food is bought and sold is equally important. For instance, what food items are available on the market? How are they priced? How accessible are the markets for men and women in the community? Who decides how much produce to keep for home consumption and what to put for sales? Who, within the household, decides how income is spend? What percentage of income is spent on food and on non-food items, such as health care, care practices that also contribute to nutrition outcomes etc.? Answers to all these questions can help design gender aware agriculture interventions.
Another important component in the fourth pathway is building awareness regarding dietary diversity as closely linked to production diversity. Agro-biodiversity creates better chances to contribute to dietary diversity. Food produced in the homestead is more likely to be consumed compared to deliberately buying the same food items for consumption. Time and labour spent mostly by women on growing such food items with limited potential to generate income is often under-valued. Improved access to reliable and remunerative markets is another critical factor that can help farmers (men and women) to obtain good prices for their surplus agricultural produce. This may require different interventions for men and for women, considering their position and resources they command within the household and in the community.
The theory of change combines the four pathways as the most effective way of achieving the desired changed in nutrition of all community members, particularly foetal, infant and young childrenâ€™s nutrition and development. The pathways are inter-related and influence each other. They cut across the four domains of nutrition, agriculture, gender and WASH as shown in the figure below. At the heart of the change are the community members, who need to be able to articulate their demands for support from key stakeholders and improvement in existing programmes and policies.
This toolkit consists of tools and methods to facilitate that process. The aim of the toolkit is to assist the community to become aware of and acknowledge the issues that negatively affect the nutrition and development of individuals and, consequently, the community as a whole. By taking the lead in the process, community members themselves will become aware of their own strengths especially indigenous knowledge and existing traditional practices that ought to be continued and built upon. Together with key stakeholders, communities will identify solutions, some of which will be implemented by the communities themselves, whilst others will require mobilising support from external organisations and partners.