Women's Awareness, Knowledge, Attitudes, and Behaviours towards Nutrition and Health in Pakistan: Evaluation of Kitchen Gardens Nutrition Program

"This SBCC [social and behaviour change communication] intervention approach which combined a range of IPC [interpersonal communication], training, incentives and community and mass media supports has demonstrated that improvements in the confidence of and competencies of vulnerable groups can be achieved within relatively short time periods."

Vulnerability to malnutrition is very high among low-income women and their children in rural Balochistan, Pakistan, with contributing factors including lack of awareness about proper nutrition, low literacy, scarcity of vegetables and fruit, and low purchasing power of households. There is increasing recognition that the problem of malnutrition is multi-faceted and requires actions with a greater focus on improvement of mothers' health literacy, including community-based education and targeted nutritional interventions. The Food and Agriculture Organization (FAO)'s kitchen garden programme provided resources to improve nutrition and health knowledge and to promote healthy eating practices. This study assessed nutrition and health awareness, knowledge, attitudes, behavioural intentions/behaviours (AKAB) of women who attended the kitchen garden programme and trainings.

Funded by AusAID and the FAO, the kitchen garden programme ran from 2015-2020. Social and behaviour change communication (SBCC) was incorporated from the beginning: Formative research with programme beneficiaries included the pre-testing, development, and dissemination of community resources including flip charts, food mats, posters, and mobile truck art, as well as development and pretesting of the preferred branding for the programme ("My Garden My Life"). Preferred message channels identified from the formative research included interpersonal communication (IPC) through opinion leaders such as doctors and lady health workers, WhatsApp groups, and the use of other support groups, with mass media channels such as radio and television also recommended channels of communication to promote kitchen garden nutrition messages.

The kitchen garden training component focused on training women and some men farmers. As part of the pilot programme, 350 community kitchen gardens were established in 6 districts in southwest Balochistan. Women from these districts were recruited to the farmer field schools (FFS) to learn new gardening concepts for the establishment of community kitchen garden (e.g., planting techniques). Supporting interventions included strengthening value chains and livelihoods systems and connecting farmers with markets for collective marketing of commodities such as onions and sheep and to enhance the overall enabling environment. The evaluation commenced within 4 weeks following completion of the final trainings.

A community based cross-sectional survey (N = 209) using a 2-stage cluster sampling method was used to select households, with survey participants being mothers with children under 5 years of age. A pretested questionnaire was administered via face-to-face surveys by trained enumerators. Nutrition and health AKAB were constructed indices. Chi-square tests compared statistical differences in AKAB by women attending against a control group who did not attend kitchen garden interventions. (True randomisation of the intervention/experimental and control group was not feasible in the resource-constrained and insecure setting, coupled with the potential for control group participants being exposed to and recalling mass media SBCC components.) Binary logistic regression analyses were performed to assess programme outcomes against key AKAB indicators, while adjusting for covariates.

Significant differences (p<0.001) were identified between intervention and control groups, with women attending kitchen garden being more aware of the components of kitchen garden (65.8% vs 36.8%) and more knowledgeable about causes of illnesses caused by poor nutrition, including iron deficiency anaemia, pregnancy, and unborn child health complications, compared to women not attending the kitchen garden programme. Logistic regression analysis indicated that women attending kitchen gardens also had higher odds of being more knowledgeable (odds ratio (OR) = 1.59, 95% confidence interval (CI) 1.27-1.99, p<0.001), having improved attitudes (OR = 4.86, 95% CI 2.77-8.53, p <0.001), and behavioural intentions/behaviours (OR = 1.98, 95% CI 1.26-3.12, p = 0.003) towards improved nutrition and health. For instance, households attending kitchen garden consumed more leafy green, vitamin-A-rich vegetables, compared to the control group with the same socioeconomic backgrounds living in the same districts.

Reflecting on the study's methodology, the researchers note that the SBCC approaches used enabled the pinpointing of where participants reside on the behaviour change continuum by identifying measures of cognition (awareness) of the health problem, knowledge, motivation, skills, and competencies, which may ultimately lead to maintenance and advocacy for the kitchen garden programme's desired behavioural objectives. Findings demonstrate that improvements in all key indicators are possible within a relatively short time period of 3 months of the pilot programme. Lessons learned include the need to further refine indicators and evaluation methodologies to account for the resource-constrained settings in which the programme was implemented and the need to institutionalise monitoring, evaluation, learning, and adaptation (MELA) as a core component in strategies to address malnutrition and food insecurity.

Future study approaches could focus on identifying the "dose/response relationship" of SBCC, which could lead to a better understanding of the impact of SBCC on participants who may have had only one level of message exposure compared to those who may have recalled multiple messages and interventions, in order to identify the optimal number of contacts needed in order to attain significant impact on the targeted behaviours. As future kitchen garden campaigns roll out on a larger scale, a fuller examination of their impact on awareness, knowledge, and additional elements such as attitudes and behaviours would be warranted, using longitudinal study designs.

In conclusion: "The findings from the kitchen garden pilot program have demonstrated the potential to achieve measurable behavioral impact through the utilization of behaviour[-]centered approaches, while acknowledging the behavioural determinants which may impact on change within complex cultural environments....Given that malnutrition and food insecurity are global challenges that are affecting a growing number of communities across the world, the evaluation findings can contribute to collective efforts in addressing these challenges by offering evidence on the effectiveness of specific strategies like kitchen garden programs supported by nutrition sensitive SBCC interventions."