Background
Methods
Part 1: Preliminary research
Analysis
Part 2: Development of Sumadhur
Part 3: Feasibility and Acceptability Pilot
Analysis
Results
Part 1: Formative research
N=200 (%) | |
---|---|
Eats last usually or all of the time | 95 (47.5) |
Did not meet minimum dietary diversity (5 or more food groups) | 177 (88.5%) |
Has been to the market since marriage | 72 (36.0%) |
Discussed how many children desired with husband | 85 (42.5) |
Feel comfortable talking to husband about sex | 64 (32.0) |
I: So, all four of you eat together?
R: No, my wife doesn’t eat with us. She eats after we all finish eating.
I: Why is that so?
R: This is because we may need to add something when we eat. If she is eating as well, it becomes difficult for her to give us additional food. Therefore, we eat at first and after we finish eating, she eats it.
I: So, does the food becomes sufficient for her?
R: Yes, it does. We usually tell her to cook food if it is insufficient. But she eats less and tells the food is sufficient for her. (Formative Phase Husband #8, age 20)
R: I like to go but who allows me to go? I don’t have anyone who accompanies me. My husband does not have much free time, nor does he have any interest. I am helpless. I also don’t have free time due to household work. If I get some free time, then I sleep. How can I have free time after marriage? I mean our life becomes imprisoned. We have to live like a prisoner. It is really hard to go for shopping after marriage.
I: Like a prisoner?
R: Yes, I mean like a chained animal. When you can’t do whatever your heart wishes, when you can’t go wherever you want to go.
I: Why?
R: In our society, people do not like when a daughter-in-law goes outside her house. It is not considered as a good thing. All we have to do is sit behind the curtain, do household chores. I have started to talk nowadays. After marriage, our life is not as before.
I: How do you feel seeing this?
R: After seeing this, I really feel sad about it. Before when I was in my maternal house, I used to go outside, eat and have fun. But now I feel that my life is limited within one house. I mean sometimes I really want to cry thinking about it (saying emotionally) (Formative Phase Wife #2, age 18)
I don't have enough information about food. I don't know what food should we take at what time. To have this information I should go out of the house, but I am not allowed to go anywhere out of the house. My husband works abroad. There is not much work in the house, there is only one person who earns money and he needs to look after seven members. Our earning are not sufficient, so it is difficult to fulfill our needs. No one else in the family is employed. We don't have good education on what we should eat, we only know that we should eat rice, lentils, but we don't know about other foods. (Formative Phase Wife #13, age 18)
I: Do you think your wife will be willing to participate in the program?
R: Yes, she will be interested to participate if the program is within the house. If it is outside, she will not be able to participate.
I: Why can't she participate?
R: It is not in our culture to allow newly married women to go outside the house.
I: And will your mother participate in such programs?
R: Yes, she will be willing to participate.
I: Will she be allowed to go outside the house and participate?
R: Yes, she will be. She doesn't have to ask anyone. She can simply inform us and go in the program.
I: So when can your wife go outside the house and participate in the program?
R: It depends; the culture here is that we have to stop her from going outside as long as we can. The people here aren’t educated and they think that women should be kept at home and men should go outside and be the bread earner. (Formative Phase Husband #9, age 21)
Part 2: Development of Sumadhur
Title | Topics and Brief Summary of Activities | |
---|---|---|
1 | Introduction | -Program welcome; participant introductions; ground rules and expectations |
2 | Marital Relationships (Couples Only) | -Topics: Healthy Relationships; Defining the Ideal Partner -Activities: practice identifying relationships and behaviors as “healthy” “unhealthy” or “depends”; guided group dialogue about ideal qualities of partners, gender roles, and relationship equality |
3 | Household Relationships | -Topics: Newly Married Life; Showing You Care Loudly -Activities: comparison of newlywed experiences, comfort, tasks, and food security; practiced identifying example scenarios of caring |
4 | Gender Inequity | -Topics: Gender Roles; Men and Boys as Drivers of Norm Change; Daily Routines -Activities: sharing of gender-specific oppressions and inequalities; guided group reflection to gender role scenarios; collaborative assessment of uneven burden of daily household chores |
5 | Gender Roles and Household Eating Patterns | -Topics: Gender Roles; Order of Household Eating -Activities: participant skit demonstrating the consequences of uneven responsibilities impacting meaningful food access; small group activity in which members distribute increasingly limited foods and discuss who is prioritized |
6 | Nutrition in Pregnancy | -Topics: Importance of Nutrition During Pregnancy; Dietary Diversity During Pregnancy -Activities: comparison and discussion of photos of depicting intergenerational outcomes of nourishment; guided group reflections about images conveying food and diet variety |
7 | Problems and Barriers to Nutrition in Pregnancy | -Topics: Nutrition During Early Pregnancy; Barriers to Adequate Nutrition During Pregnancy -Activities: dialogue responding to images of common antenatal barriers to nutrition (i.e. nausea, heartburn, etc.); small group discussions identifying barriers and solutions to eating diverse foods, iron and folic acid supplementation, and deworming |
8 | Preconception Period | -Topics: Importance of Nutrition in the Preconception Period; Reproductive Goals -Activities: dialogue following a metaphor comparing the cultivation needed for wheat and for preconception/pregnant women; individual plotting and then comparing of reproductive life plans |
9 | Norms around fertility and birth spacing | -Topics: Fertility Norms; Birth Spacing; Son Preference -Activities: discussion about community childbearing norms; storytelling to convey benefits of birth spacing; discussion of statements about social/ cultural significance of the sex of a child |
10 | Biology and Menstruation | -Topics: Introduction to Menstruation; Menstrual Hygiene -Activities: gender-specific discussions of menstruation and facilitator review of the biology of fertilization and sex determination; guided dialogue about menstrual hygiene habits |
11 | Pregnancy Care and Safe Delivery | -Topics: Importance of Antenatal Check-ups; Illness and Danger Signs During Pregnancy -Activities: interactive review of the purpose and frequency of antenatal check-ups; guided dialogue about danger signs necessitating a hospital visit and development of household-specific birth plans for safe delivery |
12 | Anemia and Iron and Folic Acid | -Topics: Birth Spacing; Anemia and Iron and Folic Acid -Activities: engagement in a metaphor of strength and weakness followed by a discussion about the intergenerational, gendered effects of anemia and possible solutions; guided dialogue and debunking of myths related to iron folic acid |
13 | Stress and Anxiety | -Topics: Adverse Events and Stress -Activities: small group discussions about causes and consequences of adverse events (i.e. unemployment, illness, relational conflict); guided practice of breathing exercises and discussion of their benefit to reduce stress and anxiety |
14 | Family Planning, Miscarriage, and Abortion (Couples Only) | -Topics: Method of Family Planning; Misconceptions Regarding Contraceptives; Miscarriage and Abortion -Activities: interactive lesson from health worker about all methods of contraception; discussion of myths and couple-specific conversations; guided dialogue on safe abortion services in Nepal |
15 | Intimate Partner Violence (Couples Only) | -Topics: Introduction to Intimate Partner Violence; Effects of Intimate Partner Violence on Women and Her Children; Ways to Prevent and Control Intimate Partner Violence -Activities: sorting of scenarios depicting intimate partner violence vs. healthy relationships and an interactive lesson defining/ describing intimate partner violence; guided dialogue about abuse and outcomes through the antenatal period; discussion of prevention and relevant laws/ policies |
16 | Closing: Making Sun | -Topics: Recalling the Sessions; Experience Sharing and Reflection -Activities: reflective sharing of key program take-aways; invitation to share experiences and partake in a celebratory meal |
Part 3: Intervention pilot results
Wives (n= 31) | Husbands (n=28) | MIL (n=31) | |
---|---|---|---|
Number session attended (max 16) | 14.35 (SD 3.5) | 15.1 (SD 2.5) | 11.9 (SD 2.5) |
Would recommend | |||
Yes | 30 (97%) | 28 (100%) | 30 (97%) |
No | 0 | 0 | 0 |
No answer | 1 (3%) | 0 | 1 (3%) |
Satisfaction | |||
Very satisfied | 27 (90%) | 28 (100%) | 21 (70%) |
Somewhat satisfied | 3 (10% ) | 0 | 9 (30%) |
Somewhat | 0 | 0 | 0 |
Unsatisfied | 0 | 0 | 0 |
Very in satisfied | 0 | 0 | 0 |
No answer | 1 | 0 | 1 |
I felt very good to participate with other community members. It felt like being in a family when people from different community, caste and family structure participated in the training. I didn’t feel that we represented different family or community. It felt as though we all were from the same family and were attending the training for mutual benefit. Maybe I felt that because everyone was cooperative, understanding and helpful….They all had their own definition and understanding on the topics covered. …in earlier days, my neighbors didn’t call me by my name. But after attending the training, they call me and ask me about the things I've learned from the training. I used to tell them the things I've learned. I also told them to participate in such trainings in future. After the training, I felt that the community here is very supportive. Other women of my age come to me and ask me about the training. I tell them about the things I've learned and also suggest them to maintain peace and mutual cooperation in the family. (Pilot Wife 13, age 21)
R:I felt comfortable to be in a group. There were other members with whom we could interact and know them better. Had it been only my family in the training, it would have been less interactive. In the institute, we try to have more students to make the class better. Similar approach was used in the training and I liked that part. It wasn’t uncomfortable with other community members. Also, it is very important to give training to community members as well. Here, the community follows traditional practices. I think such training programs will help to change their thought process.
I: What do they follow?
R: In our community, daughters-in-law cannot come outside freely, woman cannot go outside their house to work, mothers-in-law and daughters-in-law don't interact much etc. Such things need to be changed. It was somewhat similar in my household as well. But after the training it has changed a little. As I said earlier, we eat together and interact much more than before. My wife and my mother interact more and this makes me feel good. (Pilot Husband #25, age 19)
R: I was shy to attend the program at the beginning, which later on decreased. I couldn’t understand few words spoken by the facilitator, but I hesitated to ask for clarification as there were other male participants in the program. With time, I felt comfortable and my hesitation also decreased.
I: Do you want to say anything else?
R: I had not stepped outside of my home post marriage. I felt very happy to step outside of my home to attend this program. You learn some new things when you step outside of home. Attending program has increased my knowledge, I came to know about many things. I have also developed confidence for speaking. This kind of program raises awareness among people. I am very happy to be a part of this program. (Pilot Wife #3, age 20)
Even though people are educated, they feel shy in front of their family members. After participating in the training, the participant gained confidence to speak and express what they feel to their family members. The training helped in their personal development. One participant did express her feeling to me after the training. She said that she used to feel shy in front of her family members. After attending the session, her mother-in-law includes her in family conversation and encourages her to speak. In my opinion, through the training we brought closeness among daughters-in-law and mothers-in-law. If they can continue this bonding, this will help the family to become strong. (Facilitator)
Before Intervention n = 90 | After Intervention n = 90 | p-value | |
---|---|---|---|
Does everyone in the household eat at the same time together? | |||
Never | 41% (n=37) | 10% (n=9) | <0.001 |
Rarely or Sometimes | 22% (n=20) | 38% (n= 34) | |
Usually or All the time | 37% (n=33) | 52% (n=47) | |
Newly married woman ate last always or most of the time (newly married women only) | 43% | 3% | <0.001 |
Nowadays, my mother-in-law helps me a lot with my household work. As I am pregnant now, she asks me to eat egg daily saying it’s good for my health…Even if I don’t say anything, she tells me to have snacks saying that I might be hungry. She also says that I should eat more in this condition. She says eating frequent and nutritious food will be beneficial to both me and my baby inside me. (Pilot Wife #16, age 23)
My wife is pregnant, she also learned things related to pregnancy and childbirth.... Now, both my mother and my wife are trying to establish a good relationship. She is eating nutritious food and also asks for my help. In earlier days, she didn’t ask for my help in any work. I also have been helping her in household work. ...we all eat together now...My wife eats more nutritious food like green vegetables, egg, meat, cereals and lentil. We tell her to rest more and prevent her from doing any heavy work. If there’s any important work, we take suggestion from other family members before doing it (Pilot Husband #30, age 27)
I used to hear that to prevent unborn baby from gaining weight, pregnant mothers were prevented from eating nutritious food and iron tablets. But I came to know that all these weren’t true. We have to eat nutritious food, take adequate rest and consume iron tablets on time. I’ve been implementing these things in my life as well. (Pilot Wife #13, age 21)
Going together with my son and daughter-in-law, I came to know many things. It was easier for me to go together with my son and daughter-in-law. I would have been shy to talk too if I had gone alone, but going together with them became easier for me…..I have felt changes even if it’s a little. There are changes in everything regarding behavior of the family members, working environment, eating habit, conflicts. I had always wondered how would my daughter-in-law be. As she was recently married, I had not known her well. I got an opportunity to know her while going to the program. We used to go together, talk on the way and discuss about the things discussed after we would come back. We perform household work together, talk to each other and share our things. I had a negative attitude towards daughter-in-law earlier which has changed now. My daughter-in-law treats me well and so do I. (Pilot MIL #9, age 54)
I have found it so good that I cannot express in words (She said with much of excitement, and with happiness). I really liked the part where we learnt that we should not discriminate between a family who has sons with those who have daughters only. But, in villages if the family has female child only, people talk a lot behind their backs. It is not just sons who can take care of the parents even daughters can look after them….. When I went along with my son and daughter-in-law, if there were things that I didn’t understand, my daughter in law would make me sit and used to explain by saying that we were taught these things today. And when we went together, the villagers would also say that it is so nice seeing her going with her son and daughter in law to the program. I used to feel very good. (Pilot MIL #25, age 43)
R: Yes, there has been changes. The behavior towards me when I was newly married has changed after taking part in the intervention. I had to perform all the household chores by myself before but the scenario has changed now. Everyone helps with household chores. There is equal distribution of food among all the family members. We don’t fight with each other. There has been changes in husband’s and mother-in-law’s behavior. Previously, my husband used to force me for sexual relation but he doesn’t do it now. He asks about my health, respects me and loves me. I am happy now. I: Are you surprised listening to views of your family members?
R: I am surprised seeing the love and care towards me nowadays. I used to feel being neglected previously but now husband, mother-in-law, sister-in-law, brother-in-law care and love me. They help me in household chores, everyone eats together. I have understood that If a person gets good information then it is beneficial to whole family. (Pilot Wife #3, age 20)
People in the villages are still a bit ignorant, and my father-in-law comes home drunk sometimes. Well, my husband, my mother-in-law are attending the program, but my father-in-law does not understand, he needs to be taught, even he needs to be invited to the program. Everyone in the home should participate in such programs, and they should be informed about everything, such as “what would make it good and better at home”. Well, it so happens that at my home, we often have arguments and I want to make them understand (Pilot Wife #26, age 20)
My father-in-law was very curious to know about this training. He used to ask us every time. If he attends the training, he can learn many things from it. This is because, the older generation mindset takes time to change. Family and society cannot change and become progressive until and unless such older generation's mindset changes. It is important to bring changes in belief system of the head of the family. In order to bring such change, training like "Sumadhur" can play an important role. If head of the family bring change in their belief system, other members also follow it. Therefore, I think it is very essential to include father-in-law in the training. (Pilot Wife #13, age 21)