1. Part 1: Formative research:
Women were marginalized in terms of eating practices and diet, with almost half (47.5%) reporting that they ate last always or most of the time and 88.5% not meeting minimum dietary diversity standards (Table 1).
In the qualitative data, women described not eating enough and not eating foods they preferred, with one wife explaining “No one cares if I eat, what I eat. No one asks how I am feeling…. I feel no one cares about me.” (Formative Phase Wife #1, Age 18). All household respondents described ordered eating patterns, with newly married women eating last. This was often explained by “culture” or “tradition” or as a practical solution to the need for someone to be serving the food, combined with a willingness on the part of the wife to eat less, as described by one husband:
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)
Some household triads reported positive and loving relationships, but many wives felt that they were not cared for “He doesn’t help me in my work since he has married me and brought me here…My husband never asks me anything regarding my health and wellbeing. (Formative Phase Wife #11, Age 20)”
Quantitative data supported low levels of communication between spouses, with less than half of wives reporting having discussed the number of children they wanted with their husbands (42.5%) and a third (32%) feeling comfortable talking to their husbands about sex (Table 1).
Mobility was also strictly limited, with only 50% having ever left the house since marriage. In depth qualitative interviews highlighted how isolated and lonely wives were, as described below:
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). A moment of silence. (Formative Phase Wife #2, age 18)
This restriction in mobility led to barriers to women getting information about nutrition:
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 7 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)
Restricted mobility was also seen as a potentially large barrier to women being able to participate in an intervention, especially alone:
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)
In terms of the design of the intervention, respondents reported that they would prefer an intervention that engaged household members in addition to the women, and that it not be moderated by a community health care worker. Furthermore, involving husbands and mothers-in-law was also seen as an acceptable way for wives to be allowed to leave the home.
2. Part 2: Development
Our findings highlighted nutrition as a high need area, which also aligned with our goals of improving preconception health and wellbeing of women (and ultimately maternal and infant health). These findings, in combination, suggested that strengthening household relationships by bringing the three key players together (newly married women, husbands and mothers-in-law) was important, and also could be a vehicle to address household and individual practices. Bringing groups of households together could further get at community norms around expectations of women’s role and eating dynamics. We hypothesized that strengthening relationships and addressing inequitable norms could improve women’s household status, increase mobility, and increase access to food.
Based on the preliminary findings, and through the community-engaged process described above, we developed Sumadhur, a 4-month long, weekly group intervention for triads (wives, husbands, and mothers-in-law) that covers nutrition, anemia, intrahousehold food allocation, prenatal health and pregnancy care, gender inequitable norms and practices, fertility planning and contraception, and couples and household relationship dynamics (Table 2). Each session combined educational information with interactive topic-related games and activities that helped build relationships and break social and gender norms. As can be seen in Table 2, most sessions included all three household members, but a sub-set only included the wife and husband, for more sensitive topics. Detailed discussion and feedback with our partners and DAC informed the decision about which sessions should all have household members, the number of households that should be in each group, additional input about specific session content. Except in two sessions, all sessions were moderated by the trained moderators from VDRC; those two other sessions had health workers come in to provide more detailed information on family planning and biology/menstruation (Sessions 14 and 10).
3. Part 3: Intervention pilot results
i. Feasibility and acceptability:
A total of 44 households were approached initially. Ten households did not agree to be a part of the study at the first approach citing various reasons (inability to manage time, no good relation among wives and mother-in-law, the wife having gone to her maternal place for a long time). Four households backed out at the last moment citing fear of COVID-19. Therefore, an additional 4 households were approached. A total of 30 households consented to take part in the intervention. One household was again replaced after presurvey as the husband obtained visa for foreign employment. Those households were divided into 6 groups (each group comprising of 5 households). The sessions were conducted weekly in five groups, however, one group requested that they be conducted biweekly. Most of the sessions were conducted in the daytime as per the participant's choice and convenience. The sessions lasted an average of 81minutes (73-91minutes).
A total of 31 households participated, however, only 28 husbands answered the surveys. One of the husbands had gone abroad immediately after the pre-survey and did not attend any sessions. Another husband attended two sessions and then went abroad. Table 3 shows the socio-demographics of the participants.
Sumadhur was acceptable and feasible, with 97-100% of participants reporting that they would recommend it to a close friend and that they talked to someone about something they learned (Table 3). Most (83%) attended 80% of sessions or more, and the majority (73%) of participants reported “no difficulties” in attending sessions; participants identified health issues (n=12), personal work obligations (n=4), and personal household obligations (n=4) as the primary attendance barriers. Satisfaction rates were high, with 100% or respondents being very or somewhat satisfied. Additionally, there was a desire for the intervention to continue, with 99% reporting that they would like something like this to continue in the future. Additionally, despite initial hesitancy about combining husbands, mothers-in-law, and wives, 95% of wives reported that it felt “good” to attend session with their in-law.
Respondents also enjoyed the program, including interacting with others in their community, as one wife explained how it built relationships with others in her community:
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)
A husband also discussed how he appreciated the group dynamics and engagement of other community members:
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)
Despite initial concerns about constraints on women attending due to restricted mobility, Sumadhur provided an opportunity for some to leave their homes for the first time since marriage:
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)
In addition to immediate dietary changes, participants liked the information related to nutrition. When participants were asked which topics they found most useful, anemia and iron folic acid were reported most often by 61% (n=55) of participants. Topics including household relationships, gender inequality, household eating patterns, and stress and anxiety were also among the top five most useful.
We found that while engaging with sensitive and stigmatized topics together was new for many households and groups, by the sixth session comfort and engagement was reported by the facilitators to have increased across the participants.
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)
ii. Preliminary impact of the intervention
As a result of the intervention, nutritional knowledge and practices improved. There was increased awareness of the need for preconception, pregnant, lactating or postpartum women and adolescents to eat more (Figure 1). Eating patterns also shifted, with a decline in the number of daughters-in-law reporting that they ate last (from 43% to 3%) and increase in the proportion reporting that the household ate together usually or all of the time (from 37 to 52%) (Table 4).
Overwhelmingly, respondents had absorbed information about what types of foods women should eat before and during pregnancy. Intertwined with increased knowledge about nutrition itself, respondents described changing dynamics around support for women, order of household eating and awareness of the importance of strengthening relationships, as described in the two quotes below:
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)
Myths that mothers who eat too much or take iron tablets will gain weight, and other misconceptions about nutrition and health, were also dispelled, as this respondent explained:
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)
Respondents also described getting to know each other better, for example one husband told about learning something surprising about his wife: “I didn’t know that my wife was somewhat scared of childbirth. She said that she is scared of complications during her delivery. We told her not to stay worried as staying worried might cause health problems during pregnancy.” (Pilot Husband #30, age 27)
Two mothers-in-law described how it helped build a relationship with their new daughters-in-law, and how the family-group approach made them less shy about participating:
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)
A newly married women shared about how her relationship with both her husband and mother-in-law changed:
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 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)
Recommendations
All participants felt that others in their communities and other districts should have access to this program. Participants also raised that other family members should be invited to join, such as other daughters-in-law in co-resident households with multiple sons and families living together, or, most commonly, the father-in-law. One woman explained:
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)