Determinants of intra-household food allocation between adults in … · 2017. 8. 25. · REVIEW...

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Determinants of intra-household foodallocation between adults in South Asia – asystematic reviewHelen Harris-Fry1* , Niva Shrestha1, Anthony Costello2 and Naomi M. Saville3

Abstract

Background: Nutrition interventions, often delivered at the household level, could increase their efficiency bychannelling resources towards pregnant or lactating women, instead of leaving resources to be disproportionatelyallocated to traditionally favoured men. However, understanding of how to design targeted nutrition programs islimited by a lack of understanding of the factors affecting the intra-household allocation of food.

Methods: We systematically reviewed literature on the factors affecting the allocation of food to adults in SouthAsian households (in Afghanistan, Bangladesh, Bhutan, India, Islamic Republic of Iran, Maldives, Nepal, Pakistan, SriLanka) and developed a framework of food allocation determinants. Two reviewers independently searched andfiltered results from PubMed, Web of Knowledge and Scopus databases by using pre-defined search terms andhand-searching the references from selected papers. Determinants were extracted, categorised into a framework,and narratively described. We used adapted Downs and Black and Critical Appraisal Skills Programme checklists toassess the quality of evidence.

Results: Out of 6928 retrieved studies we found 60 relevant results. Recent, high quality evidence was limited andmainly from Bangladesh, India and Nepal. There were no results from Iran, Afghanistan, Maldives, or Bhutan. At theintra-household level, food allocation was determined by relative differences in household members’ income, bargainingpower, food behaviours, social status, tastes and preferences, and interpersonal relationships. Household-leveldeterminants included wealth, food security, occupation, land ownership, household size, religion / ethnicity /caste, education, and nutrition knowledge. In general, the highest inequity occurred in households experiencingsevere or unexpected food insecurity, and also in better-off, high caste households, whereas poorer, low castebut not severely food insecure households were more equitable. Food allocation also varied regionally and seasonally.

Conclusion: Program benefits may be differentially distributed within households of different socioeconomic status,and targeting of nutrition programs might be improved by influencing determinants that are amenable to change,such as food security, women’s employment, or nutrition knowledge. Longitudinal studies in different settings couldunravel causal effects. Conclusions are not generalizable to the whole South Asian region, and research is needed inmany countries.

Keywords: Food allocation, Equity, Intra-household, South Asia, Food habits, Gender, Systematic review

* Correspondence: [email protected] School of Hygiene and Tropical Medicine, Keppel Street, LondonWC1E 7HT, UKFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Harris-Fry et al. International Journal for Equity in Health (2017) 16:107 DOI 10.1186/s12939-017-0603-1

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BackgroundEvery day, households must make difficult decisionsabout how limited food should be shared among theirmembers. In low-income countries, around 793 millionpeople are undernourished [1] and over 3.5 millionmothers and children under five die every year becausethey are undernourished [2]. So, these food allocationdecisions have important nutritional, and sometimeslife-critical, consequences.It is often assumed that food is allocated inequitably in

households in the United Nations-defined region ofSouth Asia (in Afghanistan, Bangladesh, Bhutan, India,Islamic Republic of Iran, Maldives, Nepal, Pakistan, SriLanka) [3]. Tangential evidence of significantly higherfemale than male infant mortality rates [4] and socialand cultural gender discrimination that pervades nume-rous cultural and religious practices [5, 6] are suggestiveof a plausible pathway by which discrimination againstwomen leads to them not receiving their ‘fair share’ offood [7]. For instance, young women often stay at homeand avoid moving around or interacting with the com-munity (a practice known as purdah), women often de-scribe their husband as their God, and it is common forwomen to serve men first and themselves last [8, 9].International reviews have not found a consistent

global trend of inequitable intra-household food allo-cation, except in South Asia [10–12]. In South Asiathe scant evidence available suggests that women arediscriminated against and receive less than their ‘fairshare’, particularly in the allocation of high status,nutrient-rich foods [9, 13, 14]. This means that nutri-tion programs providing social transfers at the hou-sehold level may fail to reach the intended targetrecipients, such as the most undernourished or preg-nant women. On the other hand, if program imple-menters know which factors affect food allocation,and can identify those amenable to change, programscould be designed to target those individuals more ef-fectively. Furthermore, behaviour change interventionswithout social transfers, or other programs or policiesnot directly related to nutrition, may be able to in-crease intra-household equity and improve nutritionaloutcomes by pushing the right levers.However, intra-household food allocation has often

been described as a ‘black box’ that is poorly under-stood [15, 16]. This may be because economic con-sumption and nutrition surveys are typically collectedat the household rather than individual level, and alsobecause evidence has been segregated by academicdiscipline. Thus, this study aims to identify the deter-minants of intra-household food allocation, focusingon allocation between adults from South Asian house-holds, using a systematic and multidisciplinary lite-rature review.

Materials and methodsWe followed guidelines on systematic search protocolsfrom Reeves et al. [17] and Petticrew and Roberts [18]and reporting guidelines (Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) [19])when relevant.

Search methodIn two phases between October 2015 and January 2017,two authors independently ran and filtered the searchesin PubMed, Web of Science Core Collection, and Scopusdatabases. The former two databases were included be-cause they contain multi-disciplinary peer-reviewed lite-rature, and the latter database (Scopus) because itcontains non peer-reviewed literature.We used a combination of medical subject heading

(MeSH) and free text search terms, using asterisks to in-dicate a wildcard operator. The search syntax used inPubMed was:(((((family OR household*)) AND (food OR

energy intake OR food habits OR diet ORnutrition*)) AND (allocat* OR distribut*OR decision* OR shared OR sharing ORshare))) AND (age factors OR "age" OR sex OR"gender")South Asia was not used as a search term because da-

tabases have different systems for cataloguing studiesgeographically, and because international or theoreticalresults were also included. Instead, studies from otherregions were excluded in the filtering process. This in-creased the sensitivity of the search at the expense ofspecificity, giving more irrelevant (but also more rele-vant) results. Other search terms relating to ‘inequity’,and ‘determinants’ were also not included to ensure ad-equate sensitivity.

Inclusion and exclusion criteriaWe included quantitative, qualitative, anthropological,and theoretical studies from peer-reviewed and non-peer-reviewed sources that referred to the determinantsof inequity in intra-household food allocation amongadults. Inequity was defined as occurring when one per-son’s food needs were met more adequately than another’sneeds [12]. ‘Food’ could refer to calories, nutrients, foodquantities, food types, or dietary diversity, and ‘needs’were defined as biological requirements. We also includedany papers that described the determinants of inequitablefood allocation without explicitly measuring food intakesor needs if the paper referred to relative food allocationswithin households, rather than effects on absolute intakes.Recognising that the capability to control food distri-

bution decisions might be as important for wellbeingoutcomes as the resulting food allocation [20, 21], weconsidered including literature on the determinants of

Harris-Fry et al. International Journal for Equity in Health (2017) 16:107 Page 2 of 21

control over food selection, preparation, and serving.However, since this review is intended to inform nutri-tion programming, and to limit the scope, we focussedon food allocation outcomes only. Therefore, this reviewexcluded the extensive and multidisciplinary body ofwork on intra-household influences on food purchasingand preparation decisions, unless they were shown toaffect the distribution of food.We included any studies explaining inequity between

different adults (different age-sex groups or differentpregnancy or lactating status). The cut-off for adults was≥15 years because studies often include ‘women of re-productive age’ by using the age range of 15 to 49 years.We excluded papers that only referred to food allocationamong children (or between adults and children), or didnot report on food allocation directly, for example by re-ferring to anthropometry or energy expenditure. We alsoexcluded any papers that did not refer to any determi-nants other than age-sex group or pregnancy status.We included all studies relating to the UN-defined re-

gion of South Asia: Afghanistan, Bangladesh, Bhutan,India, Islamic Republic of Iran, Maldives, Nepal, Pakistan,Sri Lanka. We also included theoretical and internationalreferences that were not specific to a particular researchsetting. There was no publication date cut-off, because wepredicted that empirical and high quality evidence wouldbe limited and so did not want to exclude dated but rele-vant literature.The search results were exported into EndNote refer-

ence management software for filtering. Excluded paperswere organised into different folders labelled accordingto their reason for exclusion. Disparities in inclusion /exclusion decisions were resolved by consultation with athird author. From the systematic search results, wesearched through the reference lists to find additionalrelevant results. We added additional sources by com-munication with the authors.

Study quality assessmentTo assess the quality of quantitative results we used amodified Downs and Black checklist [22], and for qua-litative results we used the Critical Appraisal SkillsProgramme checklist [23]. Given the breadth and hete-rogeneity of results expected, a meta-analysis was notpossible and so sources of bias were not factored intothe data synthesis.

Data extraction strategyTwo authors independently extracted the author name,publication year, study location, study method, and de-terminant(s) of food allocation into Microsoft Excel da-tabases. We then mapped out each determinant onpaper, by grouping them into different themes. Theidentified themes were discussed and disparities resolved

by referring back to the text. These themes were com-piled into a conceptual framework, with discussion fromall authors.

ResultsThe result filtering process is shown in Fig. 1. Fifteen re-sults were identified from the database search, 43 resultswere added by searching references, and two paperswere added from communication with the authors, gi-ving a total of 60 results.The publication date, location, study and analysis

method, sample size and characteristics, determinants,and food allocation outcome measures for the selectedstudies are summarised in Tables 1, 2 and 3. Of the 60studies reviewed, around one quarter quantitatively esti-mated the associations between at least one determinantand food allocation, another quarter were qualitativestudies, and the remaining half made theoretical, anec-dotal, or speculative references to determinants. Nearlyevery quantitative study used a different outcome meas-ure, whereas the qualitative, theoretical and anecdotalresults tended not to define the outcome or discuss dif-ferences in nutritional requirements. Over half werefrom Bangladesh (n = 14) or India (n = 18), and aroundone third did not refer to any specific country or wereinternational reviews. Publication dates ranged between1972 and 2016, and 70% were published before 2000.

Quality assessment of selected papersThere was limited empirical evidence, a diverse range ofmethods used, heterogeneity in the outcome measure, ahigh proportion of anecdotal results, and limited metho-dological detail. This meant that it was not possible toconduct a meta-analysis of any key determinants. Qua-lity assessments for quantitative and qualitative resultsare given in Tables 4 and 5 respectively.Quality assessments showed that the results were limi-

ted by the representativeness of the samples, andmethods for quantifying and addressing non-response.Quantitative results rarely gave exact p-values (in manycases there was no statistical test) and few qualitativestudies discussed the potential influence of the inter-viewer on the respondents’ answers, the rationale fortheir sampling methods, or their analysis techniques.

Framework of determinants of intra-household foodallocationEighteen determinants emerged from the thematic ana-lysis and are illustrated in a framework in Fig. 2. Theframework also gives intuitive (rather than evidence-based) hierarchy and linkages between determinants.These linkages are not given at the intra-household level,where categorisation of a complex reality into boxes


becomes particularly difficult as determinants overlap,complement or compete with one another.The findings are narratively summarised by determi-

nant, starting at the intra-household level, then thehousehold level, and finally the distal determinants.

Intra-household level determinantsRelative economic contributions or physically strenuousworkMany theoretical or anecdotal studies suggested that se-lective investment in economically productive members(typically adult men) was a rational household survivalstrategy in the South Asian context of predominantlymanual farming labour and economic returns to health[12, 24–29]. However, these gender differences werehypothesised to differ by wealth status, with poorer house-holds being more reliant on women’s economic productiv-ity (and so more equitable) than less poor households [4].Three quantitative studies corroborated this food-

health-income link, although none directly measured theeffect of relative income on food allocation. Rathnayakeand Weerahewa [30] found that mothers’ incomes werepositively associated with their own relative calorie alloca-tions, but the authors did not adjust for total householdincome. Using body size as a proxy for economic capacity,Cantor and Associates [31] found a positive associationbetween body size and relative food allocation, although itis not known whether the authors adjusted for the higherenergy requirements associated with heavier people. Pittet al. [32] found that men’s health ‘endowments’ (pre-existing health status) determined their allocations offood, whereas women’s did not; a 10% increase in health

endowment was associated with a 6.8% increase in calorieintake for men but only one tenth of that for women [32].These differences were posited to reflect gender differ-ences in economic returns to nutritional investment.The food-health-income linkage was supported by qualita-

tive studies that reported respondents’ beliefs that incomeearners deserved to be allocated more food [33, 34], but thiswas often conflated with beliefs about physiological require-ments, particularly for manual labourers ([35] and MorrisonJ, Dulal S, Harris-Fry H, Basnet M, Sharma N, Shrestha B,Manandhar DS, Costello A, Osrin D, Saville N: Formativequalitative research to develop community-based interven-tions addressing low birth weight in the plains of Nepal.Working draft, in preparation). One study also reported be-liefs that elderly people should be allocated favoured foods toacknowledge their ‘past contributions’ to the household [36],and that men required more than women because men’swork was more physically strenuous than women’s home-based work [36]. Conversely, Hartog [28] anecdotally sug-gested that the allocation of food according to economic con-tributions was no longer justified because of the increasedmechanisation of agricultural work, and Aurino [37] sup-ported this empirically. There was no association betweengender differences in workload (with 15-year old girls workingsignificantly more than 15-year old boys) or frequency of ex-ercise and the gender differences in dietary diversity.

Cultural and religious beliefs about food properties andeating behavioursSixteen studies described cultural beliefs about foodproperties and eating behaviours as a determinant of

Results from database search(n = 6928)

Results without duplicates(n = 5985)

Duplicates excluded (n = 943)

Results after screening titles(n = 567)

Titles excluded:• Not from South Asia (n = 2524)• Not about food allocation (n = 2816)• Not about adults (n = 78)

Results after screening abstracts(n = 98)

Abstracts excluded:• Not from South Asia (n = 252)• Not about food allocation (n = 167)• Not about adults (n = 50)

Results after reading full text (n = 15)

Full texts excluded:• Not from South Asia (n = 13)• Not about food allocation (n = 47)• No mention of determinants (n = 19)• No new evidence (n = 1)• Full text not available (n = 2)• Not about adults (n=1)Results from

reference lists(n = 43)

Total studies included in review(n = 60)

Results from communication with authors

(n = 2)

Fig. 1 The exclusion of database results and inclusion of results from references and communication with authors


Table

1Quantitativestud

ies:Geo

graphicaland

metho

dologicalcharacteristicsof

selected

articles(n=16)

Autho

rYear

Stud

ymetho

dSample

size

Samplecharacteristics

Analysismetho

dDeterminant

IHFA

outcom

e

Bang

lade

sh(n=5)

Abd

ullahand

Whe

eler

[65]

1985

Long

itudinal

4x3dayWFR

53HH

RuralM

uslim

househ

olds

with

atleaston

echild

unde

r5years,fro

mon

evillage

.Men

andno

n-preg

nant,n

on-lactating

wom

en(age

notspecified

)

Analysisof

variance

Season

(March

toJulyvs

Septem

berto

Decem

ber)

RDEAR=RelativeDietaryEnergy

Adequ

acy

Ratio

(individu

alcalorie

intake

asaprop

ortion

ofbo

dyweigh

t/adultm

alecalorie

intake

asaprop

ortionof

body

weigh

t)

Bouisand

Noven

ario-Reese

[69]

1997

Long

itudinal2x

1dayWFR

590HH

Hou

seho

ldsfro

m8ruraltha

nas.Men

andwom

enaged

>18

years(average

age39

and35

yearsrespectively)

Regression

(coe

fficien

tsno

trepo

rted

)•Occup

ation(farm

eror

agriculturallabou

rer)

•Age

anded

ucationof

head

ofho

useh

old

•Land

owne

rship

FS/ES=Ratio

betw

een‘food

share’(FS),

prop

ortio

nof

totalh

ouseho

ldfood

that

ape

rson

consum

ed,and

‘ene

rgyshare’(ES),

prop

ortio

nof

househ

oldcaloriesthat

anindividu

alconsum

ed.

Kumar

and

Bhattarai[61]

1993

Long

itudinal3x

1dayWFR

300HH

Hou

seho

ldsfro

m8village

sin

4districts.

Men

andwom

enaged

>18

years

Multivariate

analysis

(morede

tailno

tgiven;

results

describ

edbu

teffect

size

notrepo

rted

)

Hou

seho

ldcaloric

adeq

uacy

Calorie‘ade

quacy’(Intakes/Requ

iremen

ts)

Pitt,Rosen

zweig

andHassan[32]

1990

Long

itudinal

1x1dayWFR

in335HH;4x

1dayWFR

in50

HH

385HH

Beng

alih

ouseho

ldsfro

m15

village

s(exclude

shilltribes).

Men

andwom

enaged

≥12

years.

Line

arregression

coefficient

Health

endo

wmen

tsCalorieintake

Tetens

etal.[72]

2003

Long

itudinal

2x1dayWFR

304HH

Tworuralvillages

inlean

andpe

akseason

s.Men

andwom

enaged

18to

<30,

30to

<60,and

≥60.

Analysisof

variance

•Season

(lean

vspe

akseason

)•Village

•Socio-econ

omicstatus

Calorieintake

India(n=8)

Aurino[37]

2016

Long

itudinal

2x1day

survey

(older

coho

rton

ly)

976HH

20clusters,w

ithover-sam

plingin

disadvantage

dareas.>90%

Hindu

,and

8%femalehe

aded

househ

olds.

Older

coho

rtof

boys

andgirls

includ

esadolescentsaged

15years.

Line

arregression

coefficient

•Pu

berty(growth)

•Scho

olen

rolm

ent

•Timeuse

•Num

berof

meals

•Ph

ysicalactivity

Dietary

Diversity

Scoreby

gend

er

Babu

,Thirumaran

andMoh

anam

[62]

1993

Long

itudinal

6x3dayWFR

120HH

1ruralvillagein

peak

andlean

season

s.Sampleinclud

esno

n-agriculturalw

orkers(m

ainlysilk

weavers),agriculturallabou

rers,

andland

owning

subsistenceor

‘market-oriented

’cultivators.

Men

andwom

en(age

notspecified

)

Descriptive

comparison

s•Season

•Occup

ation(sub

sistence,

market-o

riented,non

-agricultural,andagricultural

labo

urerho

useholds)

RDEAR=RelativeDietaryEnergy

Adequ

acy

Ratio

(Individu

alcalorie

intake

asaprop

ortion

ofindividu

alrequ

irements/Adu

ltmaleintake

asaprop

ortionof

hisrequ

irements);RD

PAR=

RelativeDietaryProteinAdequ

acyRatio

(Individu

alproteinintake

asaprop

ortionof

requ

irements/Adu

ltmaleintake

asa

prop

ortionof

hisrequ

irements)

Barker

etal.[45]

2006

Cross-sectional

1x1daysurvey

101HH

1ruralvillage,mostly

cash

crop

farm

ers.

Selected

househ

olds

containing

aminim

umof:husband

andwife

(age

Principalcom

pone

ntanalysis

•Farm

work,ho

useh

old

chores

Oilintake

(g),andfre

quen

cyof

snacking

,fasting,

andmissing

meals


Table

1Quantitativestud

ies:Geo

graphicaland

metho


selected

articles(n=16)(Con

tinued)

Basu

etal.[67]

1986

Cross-sectio

nal

1x1day24h

219HH

Hou

seho

ldsfro

mWestBeng

al,w

ithmen

andwom

enaged

>18

years.

Analysisof

variance

•Ru

ralvsurban

•Occup

ation(agriculturalist

vsplantatio

nworker)

•Religion

•Ethn

icity

•Microecon

omicsubg

roup

s

EI-ER(Energyintake

-Energyrequ

irements),

andage-sexgroups

ranked

inordero

fEI-ER

Behrman

and

Deo

lalikar

[63]

1990

Long

itudinal4x

1day24h

2roun

dsof

120HH

Threeruralvillages.

Samplingstratifiedto

includ

eland

less

agriculturallabou

rersandland

owning

cultivators.M

enandwom

en(age

grou

pno

tspecified

)

Line

arregression

coefficient

Food

priceelasticities

NAR=Nutrient

adeq

uacy

ratio

(Nutrient

intakes/Requ

iremen

ts)

Brahmam

,Sastry

andRao[66]

1988

Cross-sectio

nal

1x1day24h

1878

HH

10Indian

states,selectedho

useh

olds

with

atleaston

emem

berof

preschoo

lage.

Descriptive

comparison

for

adults

Hou

seho

ldcalorie

adequacy

(based

onintakesof

all

respon

dentswithinthe

household)

Calorieadeq

uacy

(‘ade

quate’=Calorie

intake

≥70%

Recommen

dedDaily

Intakes)

Chakrabarty

[73]

1996

Long

itudinal

2x2day24h

221HH

Threegrou

ps(highcaste,Sche

duled

Tribe,Sche

duledCaste)in

WestBeng

al.

Sampled

nuclearfamilies

with

both

parentsalive,no

n-working

wom

en(fo

rhigh

caste)

andworking

wom

en(fo

rSche

duledTribe).

t-test

Availabilityof

food

(lean

vspe

akseason

)Cerealintake–Recommen

dedcereal

intakesforabalanced

diet

Harriss-White

[27]

1991

Long

itudinal

4x1day24h

176HH

Sixvillage

sin

centraland

southe

rnIndia.

Men

andwom

en(age

notspecified

)t-test

•Season

•Region

•Land

holdingvs

land

less

RI=Relativecalorie

intakes(Individu

alintakes/Adu

ltmaleintakes)

Nep

al(n=1)

Gittelsohn

[9]

1991

Cross-sectio

nal

1x1day24h&

observation

115HH

Sixvillage

sin

Western

hills.M

enand

wom

enaged

18-24,25-49,and≥50

Correlatio

nFood

servinghabits,including

serving

orde

r,asking

forfood

,havingsecond

helpings,sub

stitu

tingfood

s,and

channe

lling

food

s.

FQS=Food

quantityscore(individu

alconsum

ptionas

aprop

ortio

nof

total

househ

oldconsum

ption/Individu

albo

dyweigh

tas

aprop

ortio

nof

total

househ

oldbo

dyweigh

t)

Pakistan

(n=1)

Governm

entof

Pakistan

[38]

1979

Cross-sectio

nal

1x24h

975HH

Malehe

adof

househ

old,

plus

wom

anof

childbe

aringage(preferablypreg

nant

orlactating)

andallchildrenaged

unde

r3years.

Line

arregression

(coe

fficien

tsno

trepo

rted

)

•Education

•Region

•Hou

seho

ldsize

•Income

Individu

alintake

/Hou

seho

ldintake

(calories,protein,

ironandvitamin

A)

SriLanka

(n=1)

Rathnayake

and

Weerahe

wa[30]

2002

Cross-sectio

nal

1x24h

60HH

Hou

seho

ldsfro

mlower

incomegrou

pin

urbanKand

y.Fathersandmothe

rs(age

notspecified

)

Line

arregression

coefficient

andt-test

•Mothe

r’sincome

•Mothe

r’sed

ucation

•Ethn

icity

•Family

size

RCA=Relativecalorie

allocatio

n(calorie

intake

asaprop

ortio

nof

recommen

ded

allowance

/Hou

seho

ldintake

asa

prop

ortio

nof

househ

oldallowance)

WFR

Weigh

edfood

records,24h24

-hou

rdietaryrecall,HHHou

seho

lds


Table

2Qualitativestud

ies:Geo

graphicaland

metho


selected

articles(n=15)

Qualitativestud

ies(n=15)

Autho

rYear

Stud

ymetho

dSamplesize

Samplecharacteristics

Analysismetho

dDeterminant/them

eIHFA

outcom

e

Bang

lade

sh(n=4)

Abd

ullah[36]

1983

Unstructured

interviews

40HH

One

ruralM

uslim

village

incentral-w

estBang

lade

sh.

Mostly

malerespon

dents.

Particularlyin

poor

househ

olds,

wom

enalso

participated

.

Notes

recorded

onpape

r,andresults

analysed

bywealth

grou

p.

•Econ

omiccontrib

utions

•Normsrelatin

gto

receivinga‘fairshare

•Food

securityandscarcity

•Hou

seho

ldstructure

(allocatio

nto

wom

enin

parentalvs

maritalh

omes)

Food

allocatio

n

Mukherjee[75]

2002

Season

alcalend

ar1grou

pNot

repo

rted

Metho

dof

quantifying

discrim

inationno

tspecified

•Season

Discrim

ination

inconsum

ption

offood

items

andtype

s

Naved

[35]

2000

Focusgrou

pdiscussion

s,case

stud

ies,andothe

rmetho

ds.

Casestud

ies

of22

wom

en;

19men

Threevillage

sparticipating

inan

agriculturalp

rogram

.Maleandfemalebe

neficiaries

oftheprog

ram.

Triang

ulationof

multip

lequ

alitative

techniqu

es

•Ph

ysicallystrenu

ous

labo

urcontrib

utions

•Bargaining

power

•Individu

alstastes

and

preferen

ces(wom

eneatin

gmoreless-preferred

food

sthan

men

)•Food

availability(Seemingly

contradictoryanecdo

testhat

increasedfood

availabilitydid

notchange

food

allocatio

npatterns

much,bu

tfood

scarcity

ledto

men

beingless

likelyto

have

sufficien

tfood

than

wom

en.)

Allocatio

nof

specificfood

items

Rohn

erand

Chaki-Sircar

[71]

1988

Observatio

n?(limiteddetail)

1village

Not

repo

rted

Not

repo

rted

•Caste

-Highcastemen

andbo

yshadthebe

stqu

ality

food

,especially

eggs,m

ilkandfish.Impliedthat

this

islessthecase

with

lowercaste

households.

Food

quality

India(n=7)

Caldw

ell,Redd

yandCaldw

ell[51]

1983

In-dep

thqu

estio

nsandcase

stud

ies

50%

of4773

popu

latio

n(n=2387)

One

largevillage

andeigh

tsm

allervillage

sin

ruralarea

ofsouthe

rnKarnataka.

Individu

alrespon

dent

characteristicsno

trepo

rted

.

Dailyscrutin

yof

finding

sandon

-going

mod

ificatio

nof

questio

nsto

iden

tify

behaviou

ralp

atterns

•Beliefsabou

teq

uity

-Respon

dents

werereluctantto

talkabou

tfood

allocatio

n.This“dem

onstratesthe

existenceof

somebe

liefin

equitable

distrib

ution”.Ine

quity

was

“asmuch

amatterof

poor

commun

icationas

ofde

liberateintent”.

•Interpersonalrelationships

–Differen

tialfoo

dallocatio

nwas

inde

clinedu

eto

thestreng

then

ing

bond

betw

eenhu

sbandandwife.

Food

allocatio

n


Table

2Qualitativestud

ies:Geo

graphicaland

metho


selected

articles(n=15)(Con

tinued)

Daivadanam

etal.[59]

2014

Interviewsandfocus

grou

pdiscussion

s17

individu

als;

3grou

ps

Ruralareas

(one

coastal

andon

eno

n-coastal)

Men

andwom

enaged

betw

een23

and75

years,

ofdifferent

religions

and

socio-econ

omicstatus.

Mostly

femalehe

adsof

househ

oldandothe

rsinvolved

indietaryde

cision

-making.

One

grou

pmostly

comprised

ofmen

.

Mod

ified

framew

ork

analysisusing

indu

ctiveand

dedu

ctivereason

ing–

didno

ttryto

fitthe

data

into

pre-iden

tified

them

es.

•Tastes

andpreferen

ces-wom

enprioritised

theirow

nfood

preferen

cestheleast

Allocatio

nof

preferredfood

s

Katona-Apte

[39]

1977

In-dep

thinterviews

62preg

nant

wom

enor

mothe

rs

Twodistrictsfro

mTamilNadu.

Allho

useh

olds

hadatotal

incomeof

<200Indian

Rupe

espe

rmon

th.

Allfemalerespon

dents,andmost

werepreg

nant,lactatin

g,or

amothe

rof

child

unde

rtw

oyears.

Analysismetho

dno

trepo

rted

.•Cu

lturalbeliefsabou

tfood

s–

pregnant

andlactatingwom

enavoidedcertainfood

s,andthis

caused

them

tohave

less

adequate

diets,particularlyif

therewas

lack

ofvarietyor

budg

etto

replaceavoided

food

swith

nutritiou

salternatives

Allocatio

nof

specificfood

type

sthat

have

different

prop

erties

Khan

etal.[33]

1987

In-dep

thinterviews

andparticipant

observations

20individu

als

One

stud

yvillage

from

western

Uttar

Pradesh

20mainfemaleinform

ants

(age

notrepo

rted

)fro

mdifferent

casteandclass

grou

ps,and

extensive

discussion

swith

othe

rvillage

rs,including

men

.

Analysismetho

dno

trepo

rted

.•Econ

omiccontrib

utions

-Respon

dentssaid

that

men

shou

ldeatmorebe

causethey

earn

andprovideforthefamily.

Thebe

liefthatmen

shou

ldbe

givenmorefood

was

rarer

(3/6respon

dents)whe

nwom

enearned

anincome.

Somewom

enateless

because

they

didno

thave

timeto

eat.

Wom

enhadless

appe

titedu

eto

fatig

ueaftercookingand

servinghe

rfamily

mem

bers.

•Religious

andcultu

ralb

eliefs-

Wom

en“enjoy

thisspiritof

sacrifice

forthefamily”.There

was

also

abe

liefthat

preg

nant

wom

enshou

ldeatgh

ee(clarifiedbu

tter)to

give

lubricationdu

ringbirth.The

cultu

raln

orm

ofthefemale

cook

eatin

glastmeant

that

wom

eneatless.

•Status

-Wom

enhadareligious

obligationto

fastforthefamily

andformen

tohave

supe

rior

status

andallocatio

nof

food

.•Hou

seho

ldincome-In

poor

househ

olds,the

eatin

gorde

rne

gativelyaffected

wom

en;in

wealth

yland

owning

families

itdidno

t.

Allocatio

nof

food

gene

rally,

andalso

ofspecificfood

items


Table

2Qualitativestud

ies:Geo

graphicaland

metho


selected

articles(n=15)(Con

tinued)

Miller

[58]

1981

Review

ofethn

ograph

ies

58stud

ies

Review

ofmanystud

iesfro

macross

India.

Meta-analysis


-Servingfood

was

away

that

wom

enshow

love

andaffection

totheirmen

.Sim

ilarly,refusing

toeatfood

was

acommon

metho

dforaman

topu

nish

hiswife

ormothe

r.

Food

allocatio

n

Nicho

ls[74]

2016

Semi-stru

ctured

interviews,and

inform

alconversations

and

participant

observation

81individu

als

Four

village

sin

sub-Him

alayan

district.

Respon

dents:Governm

ent

workers,N

GOem

ployees,

village

men

,wom

en,and

coup

les.Co

nveniencesampling

toinclud

erespon

dentsfro

mdifferent

class,caste,age,gend

erandho

useholdcompo

sition.Plus,

national-levelNGOrepresentatives

from

Delhi.

Them

aticanalysis,

bycoding

them

esandintersectio

nsbe

tweenthem

es

•Labo

ur/ph

ysicallystrenu

ous

econ

omiccontrib

utions

-wom

enatetheleastdu

ringplantin

gand

harvestseason

swhe

nthey

were

working

thehardest(and

working

harder

than

men)d

ueto

alack

ofappetitefro

mtheexhaustio

nof

thelabo

ur

Food

allocatio

n

Palriwala[34]

1993

Participant

observation

1village

Sikardistrict,ruralagricultural

village

with

Hindu

(85%

)and

Muslim

(15%

)castes.

Individu

alparticipant

characteristicsno

trepo

rted

.

Not

repo

rted

•Culturalb

eliefs/eatin

gorde

r-

youn

gestdaug

hter

inlaw

usually

cooksandeatslast,leading

toless

diversediet

astheremay

beno

lentils

orvege

tables

left.

•Food

scarcity

–eatin

gorde

rparticularlyaffected

thedaug

hters

-in-law

durin

gfood

scarcity.

•Econ

omiccontrib

utions

affect

food

allocatio

n–incomeearners

aregivenpriorityof

delicacies

andnu

trient-richitemslikegh

ee,


–food

allocatio

naffected

bykinship

status,p

articularlyagnatio

n.

Allocatio

nof

specificfood

items

Nep

al(n=4)

Gittelsohn

,Thapaand

Land

man

[41]

1997

Keyinform

antinterviews,

participantob

servation,

unstructured

pilot

observations,focus

grou

pdiscussion

s,and

structured

pilesorts

105HH

Sixruralvillages,with

amixture

ofagriculturaland

non-agricultural

occupations.

Men

aged

18to

50years,and

wom

enaged

18to

50years,

includ

ingmen

struating,preg

nant,

lactating,

andpo

stpartum

wom

en.

Analysismetho

dof

qualitativeresults

notrepo

rted

•Culturalb

eliefs-Men

were

considered

theleastvulnerable

andthereforehadthefewest

dietaryrestrictio

ns,unlessthey

wereill.O

lder

peop

leconsidered

vulnerableandbe

lievedto

requ

irestreng

then

ingfood

s.Some

preg

nant

wom

enmen

tione

dpreferen

tially

eatin

ganim

alprod

uctsdu

eto

‘craving

’.Po

st-

partum

wom

enavoide

d‘cold’

food

sand‘indige

stible’foo

dslike

whe

atbread,

peanuts,soybeans

andcorn

porridg

e.They

preferentially

atecertain‘hot’foo

dslikefishand

Allocatio

nof

‘special’food

s


Table

2Qualitativestud

ies:Geo

graphicaland

metho


selected

articles(n=15)(Con

tinued)

mille

troti.Lactatingwom

enavoided

fresh

greenleafyvegetables

that

wereperceivedas

‘cold’and

believed

tocausearthritis,sw

ellingandother

illnesses.

•Status

-Wom

en’sstatus

increased

byhaving

children.Before

childbe

aring,

youn

gmarriedwom

enhadlow

status

andweresubtlydiscou

rage

dfro

meatin

gspecialfoo

dslikeanim

alprod

uctsandcertainfried

food

s.Men

’shigh

erstatus

was

“recog

nised

inmanyways,includ

ingho

useh

old

food

behaviou

r”

Madjdian

andBras

[40]

2016

In-dep

thinterviews

30individu

als

TwoHim

alayan

commun

ities

from

Hum

ladistrict.

Femalerespon

dents(15Budd

hist;

15Hindu

Dalitor

Chhetri)o

freprod

uctiveage(aged15

to49

years).Selectedrespon

dentswho

werepregnant

orhadbeen

pregnant

atleasto

ncebefore.

Indu

ctivecoding

based

onaconcep

tual

framew

ork,using

bottom

-upandtop-

downcoding

toallow

newthem

esto

emerge.

•Beliefsabou

t‘fairshare’/Religion-

Budd

histho

useh

olds

allocatedfood

accordingto

appe

tite;thiswas

not

repo

rted

inHindu

househ

olds.

•Culturalb

eliefsandfood

habits-

Certain

food

sbe

lievedto

cause

skin

allergies.Eatin

gorde

rwas

associated

with

eatin

gless.

•Food

security-Food

insecure

househ

olds

didno

tadhe

reto

food

proscriptio

nsdu

eto

alack

offood

Food

allocatio

n

Morrison

,J.etal.

Form

ativeresearch

toinform

the

developm

ent

ofinterven

tions

totacklelow

birth

weigh

tin

therural

plansof

Nep

al.

Inprep

aration.

Unp

ublishe

dob

servations

Interviewsandfocus

grou

pdiscussion

s25

wom

en,

2grou

ps.

One

districtin

Terai.

25youn

gdaug

hters-in-law

from

marginalised

grou

pslivingin

extend

edfamilies,one

focus

grou

pdiscussion

with

men

,and

onewith

FemaleCom

mun

ityHealth

Volunteerswho

were

mothe

rs-in

-law.M

ost(90%

)respon

dentswereHindu

.Respon

dent

ageno

trepo

rted

Descriptiveconten

tanalysis.D

atawere

copied

from

transcrip

tsinto

columns

of15

descrip

tiveem

erge

ntcatego

ries.

•Status

-Respon

dentsrepo

rted

that

men

atemorebe

causethey

hadhigh

erstatus

andso

deserved

to.


-Husband

smay

hide

food

for

theirpreg

nant

wives,

disrespe

ctingthemothe

r-in-law.

•Hou

seho

ldstructure-Married

wom

enwho

visitedor

lived

attheirmaternalh

omes

hadfewer

food

restrictio

ns.

•Econ

omiccontrib

utions

–Manual

labo

urerswerepe

rceivedto

deservemore

•Culturalfoo

dbe

liefs–preg

nant

wom

enateless

(fear

offull

stom

achharm

ingthebaby)

•Hou

seho

ldincome–no

effect

offood

beingbo

ught

vsgrow

non

food

decision

s.

Allocatio

nof

food

gene

rally,

andalso

of‘sp

ecial’food

s


Table

2Qualitativestud

ies:Geo

graphicaland

metho


selected

articles(n=15)(Con

tinued)

Panter-Brickand

Egge

rman

[64]

1997

Semi-structured

interviews

120he

adsof

househ

old

Popu

latio

nof

high

andlow

casteIndo

-Nep

aleseand

Tibe

to-Burmeseethn

icgrou

psfro

mfour

Pancha

yatsin

two

districts.

Sampled

househ

olds

toen

sure

prop

ortio

nalrep

resentationof

largeandsm

allland-ho

lding

farm

ers

Age

ofrespon

dentsno

trepo

rted

.

Analysismetho

dof

qualitativeresults

notrepo

rted

.

•Food

shortage

s/Ethn

icity

-Indo

-Nep

aleseho

useh

oldused

discrim

inationagainstwom

enas

acoping

mechanism

durin

gfood

shortage

swhe

reas

Tibe

to-

Burm

eseho

useh

olds

didno

t.

Food

allocatio

n


Table 3 Studies with theoretical, hypothetical or general mention of determinants – author, year, determinant and food allocationoutcome (n=29)

Author Year Determinant IHFA outcome

Bangladesh (n = 5)

Chaudry [70] 1983 Household size Relative calorie adequacy

Chen, Huq and d’Souza [4] 1981 Relative economic contributions Allocation of food quantity andquality

Kabeer [44] 1988 Cultural beliefs / serving order Food allocation

Rizvi [50] 1981 Relative social status Food allocation

Rizvi [68] 1983 Household wealth (poverty)Household size

Food allocation

India (n = 3)

Cantor and Associates [31] 1973 Relative economic contributions (proxied by body size)Household wealth

Food allocation

Coffey, Khera andSpears [47]

2015 Relative social status Food allocation

Das Gupta [49] 1996 Relative social status (having sons)Nutrition knowledge

Relative calorie adequacy

Nepal (n = 1)

Gittelsohn, Mookherji andPelto [42]

1998 Cultural food beliefsHousehold food insecurity

Food allocation

South Asia (n = 2)

Agarwal [56] 1997 Bargaining power Food allocation

Appadurai [8] 1981 Relative cultural status / life cycle in the householdBargaining powerInterpersonal relationships

Food allocation

International (n = 16)

DeRose, Das andMillman [14]

2000 Relative social statusDecision-makingNutrition knowledge

Calorie and food allocation

Haddad and Kanbur [25] 1990 Control over incomeFood insecurity

Calorie and food allocation

Haddad et al. [11] 1996 Decision-making (identify of decision-maker)Food insecurity

Food allocation

Haddad [54] 1999 Control over incomeFood insecurity

Food allocation

Kumar [26] 1983 Decision-making Food allocation

Messer [48] 1997 Relative social status (the traditional role and perceptions of women)Beliefs about fairness

Food allocation

Pinstrup-Andersen [15] 1983 Nutritional needPreferencesDecision-makingHousehold income

Food allocation

Wheeler [12] 1991 Relative economic contributionsBeliefs about fairnessBargaining power

Allocation of nutrient-rich foods

Carloni [53] 1981 Decision-makingSocial mobility / participation in shopping

Food allocation

Hartog [28] 1972 Economic contributionsCultural beliefsSocial statusInterpersonal relationships

Food allocation

De Schutter [52] 2013 Beliefs about fairnessControl over food production or purchasingFood insecurity

Food allocation


food allocation, typically showing how these beliefscaused women to receive comparatively less.Some foods were believed to be ‘unhealthy’, ‘streng-

thening’ or ‘digestible’, and therefore deliberately avoidedor selected by vulnerable people, such as elderly people, orpregnant or lactating women [28]. Short-term ‘transitory’states, such as menstruation and illness that are perceivedto make a person ritually unclean (‘jutho’ (Nepalese)),were reported to cause inequity in food allocation [9, 38].Certain fruits and vegetables were considered unhealthy

for post-partum or lactating women [9], and other foodswere believed to cause illness [39] or skin allergies [40] inthe breastfeeding child. Elderly people were believed to re-quire soft ‘digestible’ [9] and ‘strengthening’ foods [39, 41].Pregnant women were reported to require ghee (clarifiedbutter), to facilitate an easier, lubricated birth [33], butavoid certain foods that cause illness, indigestion, fits, de-lirium, or large babies (and therefore difficult labour) [39]and eat less because of a belief that a full stomach wouldharm the baby (Morrison J, Dulal S, Harris-Fry H, Basnet

Table 3 Studies with theoretical, hypothetical or general mention of determinants – author, year, determinant and food allocationoutcome (n=29) (Continued)

Den Hartog [43] 2006 Religious beliefsBeliefs about fairness

Food allocation

Gunewardena [60] 2014 Food insecurity Food allocation

Pelto [46] 1984 Social status (in relation to modernisation and urbanisation) Food allocation

Ramachandran [55] 2007 Decision-making / control over incomeBargaining powerFood insecurityHousehold composition (nuclear vs joint households)

Food allocation

Van Esterik [29] 1985 Economic contributionsOverlap between cultural beliefs during pregnancy, social status, andpovertySocial mobilityInterpersonal relationshipsHousehold size (number of senior women)ReligionFood availability

Food allocation

No countries mentioned (n = 2)

Doss [24] 1996 Relative economic contributionsBargaining power

Food allocation

Hamburg et al. [57] 2014 Interpersonal relationships Food sharing

Table 4 Quality assessment of quantitative results (n = 16) using an adapted Downs and Black checklist

Study quality No Unable to determine Yes

n n n (%)

Is the hypothesis or aim of the study clearly described? 0 NA 16 (100)

Are the outcomes described in the Introduction or Methods? 1 NA 15 (94)

Are the characteristics of the respondents described? 6 NA 10 (63)

Are the determinants of interest described? 2 NA 14 (88)

Are the distributions of principal confounders described? 6 NA 10 (63)

Are the main findings of the study clearly described? 1 NA 15 (94)

Does the study provide estimates of random variability? 9 NA 7 (44)

Have probability values (not cutoffs) been reported? 14 NA 2 (13)

Validity, bias and confounding

Was the sample representative of the population? 1 7 8 (50)

Were the respondents representative of the population? 0 14 2 (13)

Were the statistical tests appropriate? 4 0 12 (75)

Were the main outcome measures used valid and reliable? 0 3 13 (81)

Was there adequate adjustment for confounding? 8 2 6 (38)

Were losses of respondents taken into account? 3 11 2 (13)


M, Sharma N, Shrestha B, Manandhar DS, Costello A,Osrin D, Saville N: Formative qualitative research to de-velop community-based interventions addressing lowbirth weight in the plains of Nepal. Working draft, inpreparation). Another phase condition is puberty; accord-ing to the ‘pubertal hypothesis’ households might changeintra-household food allocation in favour of adolescentsgoing through pubertal growth spurts, however this wasnot supported empirically [37].The categorisation of foods as heating, neutral or coo-

ling was also linked to differential food allocation [9].Examples of ‘heating’ foods included wheat, fish, millet,and milk, and ‘cooling’ foods included yogurt, fruits,green beans, gourds, and rice [41]. Again, these catego-ries were related to the condition of the individual; forinstance, lactating women avoided cooling foods [41].Some authors noted that these restrictions caused anoverall reduction in women’s dietary intake [41] perhapsdue to insufficient household budget for nutritious alter-natives [39]. The overlap of women being in the ‘phasecondition’ of being pregnant, having low social status,and extreme poverty, was hypothesised as a cause of ine-quitable allocation of food towards pregnant women[29], whereas another study found that food insecurehouseholds did not adhere to food proscriptions due toa lack of food [40].

Cultural beliefs about the status or value of foods werealso linked to food allocation [42]. Some people were al-located or ‘channelled’ specific foods, and these foodswere often high status and expensive. For example, ghee(a high status food) was often only given to men [9](perhaps with the exception of pregnant women, as docu-mented earlier). Food ‘channelling’ was associated withsignificantly higher food quantities, so those who weregiven special foods were also given more food in total [9].Religious beliefs may affect the distribution of food.

For example, beliefs about the meaning of food, such asthe act of eating being considered a form of worship inIslam, was suggested as a determinant of food allocation,although the direction of effects was not specified [43].Fasting caused women to be allocated comparatively lessfood, because women fasted more frequently and strictlythan men [27, 33].Eating order was another key factor in food eating and

allocation behaviours. Daughters-in-law, often young,newly married women, tended to serve themselves last(to show deference and ensure the wellbeing of malemembers [44]) and this was associated with eating less[9, 33, 40] and also lower quality diets than others [34, 45].Gittelsohn [9] found that late serving order at meal times,being the food server, and not having a second helpingwere all significantly negatively associated with the quantityof food consumed. Two authors suggested that the nega-tive effects of serving order were caused by limited foodavailability, because women tended to ensure everyoneelse had enough before serving themselves the re-mainder [9, 44].

Relative social status within the household, according tocultural normsHigh social status and perceived deservedness of house-hold members was reported by 14 studies as a determi-nant of intra-household food allocation, although nostudies quantified the effect empirically. Some men-tioned status in general terms, without ascribing high orlow status to particular household members but sugges-ting that people with lower status would receive lessfood and less preferred foods [12, 14, 28, 29, 46],whereas others reported that men had higher status andtherefore were allocated more food [9, 41, 47]. Pelto [46]noted that modernisation and increasing urbanisationwas reducing the effect of status on food allocation.Women’s identity as being lower status, frugal, modest,

and subservient was described as a determinant of foodallocation that favoured men but was often internalisedby women [33, 48]. This identity was also interlinkedwith perceptions of body image, that also led women toeat comparatively less [48].In addition to differences between genders, food allo-

cation was also determined by differences in social

Table 5 Quality assessment of qualitative results (n = 15) usingCritical Appraisal Skills Programme (CASP) checklist

Critical Appraisal Skills Programme(CASP) quality indicator

No Unable todetermine

Yes

n n n (%)

Was there a clear statement of the aimsof the research (the goal, importance,and aims)?

0 0 15 (100)

Is a qualitative methodology appropriate? 0 0 15 (100)

Was the research design justified asappropriate to address the aims of theresearch?

0 7 8 (53)

Was the recruitment strategy justified asbeing appropriate to the aims of theresearch (how and why respondentswere sampled, or discussions ofnon-response)?

0 7 8 (53)

Were the data collected in a way thataddressed the research issue (detail andjustification of methods, issues of datasaturation)?

0 9 6 (40)

Has the relationship between researcherand participants been adequatelyconsidered?

0 9 6 (40)

Have ethical issues been considered(informed consent and ethical approval)?

0 13 2 (13)

Was the data analysis sufficiently rigorous? 0 10 5 (33)

Is there a clear statement of findings? 1 0 14 (93)


rankings among women within households [47], hier-archy within the patriline [34], and variations withinindividuals over time. Women received more food astheir status increased with age [9], by having children[41], and, particularly, by having sons [49]. In contrast,Rizvi [50] anecdotally suggested that increases in femalestatus over time did not affect food allocation.

Belief that everyone should be given their ‘fair share’Overlapping these beliefs about food properties and sta-tus were locally-held beliefs about fairness, and differentdefinitions of what ‘fair’ means [48]. An Indian studyconcluded that beliefs about fairness affected food allo-cation because the respondents were reluctant to discussdisparities in food allocation [51]. Abdullah [36] also in-dicated this, by reporting a respondent’s description of amother-in-law as a “bad woman” (p112) if she did notgive her daughter-in-law special foods that others re-ceived, and Madjdian and Bras reported that Buddhisthouseholds allocated food according to appetite [40]. Pittet al. reported that the tendency for households toequalise food allocation, rather than allocate food in anincome-maximising way, was a reflection of households’aversions to inequity [32]. Pinstrup-Andersen also hypo-thesised that perceived nutritional need determined foodallocation (arguably a definition of fairness) [15].

Conversely, three others reported an ideological belief thatmen deserved to be given more than women [33, 43, 52].

Decision-making, social mobility, and control over resourcesThe ten studies on decision-making, control over resources,social mobility, or identity of the cook were all anecdotal ortheoretical. Few specified who the decision-maker was or whowould benefit from the decisions [15, 26, 53]. Haddad et al.noted that female decision-makers may be more likely thanmale decision-makers to allocate food in a way that maxi-mised the household’s nutritional outcomes [11], and otherwork suggested that women’s control over income [25, 54, 55](or production or purchasing [52]) would affect food alloca-tion in favour of women. However, decision-making in nuclearhouseholds was also a risk factor for inequitable allocation to-wards women, as female decision-makers were responsible forensuring that everyone else was sufficiently fed [55].Related to this was different household members’ social

mobility, and freedom to go food shopping or access foodoutside of the home [29, 53]. Women were described ashaving less social mobility and this was linked to lowerfood allocations [53]. However, it was also suggested thatthere may be less inequity against women than expectedbecause food allocation occurs within the household,which, compared with the public sphere, is a domain inwhich women traditionally have more control [14].

Household food security and scarcity

INTRA-HOUSEHOLD FOOD ALLOCATION

Village and regionSeasonality

Religion, ethnicity and caste

Educational levels

Land ownership

Household size / structure

HOUSEHOLD-LEVEL DETERMINANTS

Cultural and religious beliefs about food properties and eating

behaviours

Belief that everyone should be given their ‘fair share’

Relative status within the household, defined by cultural norms

Decision-making, social mobility and control over

resources

Bargaining power

Food as a means to establish and reinforce interpersonal

relationships

Relative economic contributions or

physically strenuous work

Individual tastes and

preferences

INTRA-HOUSEHOLD DETERMINANTS

DISTAL DETERMINANTS

Nutrition knowledge

Economic factors Cultural factors Social processes

Household wealth and income

Household occupation

Fig. 2 Determinants of intra-household food allocation and hypothesised hierarchical structure


Bargaining powerRelated to this, many studies suggested that ‘bargainingpower’ was an important determinant of food allocation.Some described a general linkage [55], while others de-scribed various microeconomic theories whereby indivi-duals rationally aim to maximise their utility bybargaining over household resources such as food [12,24, 56]. The strength of a person’s bargaining power isdetermined by their ‘fallback position’ (the utility thatthe individual would achieve if cooperation with otherhousehold members fails). Bargaining power may be pre-dicted by the size of dowry for women [55], social normsthat determine how goods such as food can be ex-changed or used, and /or perceived requirements [56].Naved also indicated that bargaining power might affectfood allocation, with specific reference to micronutrients[35]. Appadurai described the process of bargaining withfood, particularly in reference to daughters-in-law feelingresentment about their subservient role [8]. Daughters-in-law were reported to communicate resentment by be-ing reluctant to cook, destroying food, or making smallsigns of discontent when serving food [8].

Food as a means to establish and reinforce interpersonalrelationshipsA study on the psychology of feeding found that foodserving may be determined by the emotional state of theserver and recipient, and that feeding was done to buildrelationships [57]. Serving and eating food was reportedas a key determinant of intra-household food allocation[34] and a means to indicate rank [8], show disrespect ordispleasure ([58] and Morrison J, Dulal S, Harris-Fry H,Basnet M, Sharma N, Shrestha B, Manandhar DS, CostelloA, Osrin D, Saville N: Formative qualitative research todevelop community-based interventions addressing lowbirth weight in the plains of Nepal. Working draft, inpreparation), punish or reward people [29], or express loveand strengthen relationships [28]. Two studies suggestedthat a strong bond between husband and wife might re-duce the inequity against the wife that would otherwise beimposed by the mother-in-law ([51] and Morrison J, DulalS, Harris-Fry H, Basnet M, Sharma N, Shrestha B, Mana-ndhar DS, Costello A, Osrin D, Saville N: Formative quali-tative research to develop community-based interventionsaddressing low birth weight in the plains of Nepal. Work-ing draft, in preparation).

Individual tastes and preferencesOne study [15] reported a general hypothesis that foodpreferences determine allocations. One study found thatwomen were allocated the less-preferred foods [35], andanother found that women prioritised their own foodpreferences the least [59]. A new vegetable productionprogram, which had increased the availability of less

popular vegetables, had caused an increase in women’sconsumption of those vegetables [35].

Household-level determinantsFood insecurity and scarcityEvidence on the effect of household food security wasmixed. Seven studies provided a hypothetical link be-tween food insecurity and food allocation [11, 25, 42,52–54, 60].Most studies suggested that women were more sensi-

tive to changes in food availability, and acted as a bufferfor the household in food insecure conditions [40, 52, 55],particularly the youngest daughter-in-law [34]. Householdcalorie adequacy was a better predictor of calorie ade-quacy for women than for men [61], years of higher riceyields were linked to higher equity in calorie allocation[62], and women were more sensitive to food pricechanges (had higher food price elasticity) than men [63].Although one study found no overall effect of food inse-curity, there were differential effects between villages, andin food-scarce months landowning households favouredmen at the expense of women while labourer householdsfavoured adults at the expense of children [27]. Anotherstudy found some ethnic variability in these effects, withIndo-Nepalese household using discrimination againstwomen as a coping mechanism during food shortages andTibeto-Burmese households not changing their food dis-tribution patterns in this way [64].In contrast, some studies found opposing or no effects.

Naved found that increased food availability did notaffect food allocation patterns, but food scarcity led tomen being less likely to have sufficient food than women[35]. Abdullah also found women’s proportion of men’sintakes increased from 81 to 90% between food secureand food short seasons, in poor households [36]. A lateranalysis by the same authors found no significant effectafter adjusting for differential requirements [65], andanother also found no effect of scarcity on calorieallocation [66].

Household wealth and incomeEvidence was mixed on the effect of household wealth andincome. Three quantitative studies reported no effect [31,38, 67], while Pinstrup-Andersen’s [15] theoretical studyhypothesised that there was an effect without specifyingthe direction. Two qualitative studies reported higher in-equity in poorer households [33, 68], but a qualitative studyreported that the source of food, whether bought or grown,had little effect on food decisions (Morrison J, Dulal S,Harris-Fry H, Basnet M, Sharma N, Shrestha B, Mana-ndhar DS, Costello A, Osrin D, Saville N: Formative quali-tative research to develop community-based interventionsaddressing low birth weight in the plains of Nepal. Work-ing draft, in preparation).


Educational levelsHouseholds with more educated household heads allo-cated less meat to women than men [69], whereas an-other two studies on female education showed noassociation with food allocation [30, 37].

Nutrition knowledgeAlthough studies linked food beliefs and food allo-cation, no studies measured the association betweendietary knowledge and food allocation. Das Guptasuggested that lack of knowledge did not explain thecomparatively inadequate intakes of pregnant andbreastfeeding women in India [49], whereas others sug-gested the opposite [14, 38].

Household occupationOne study found that the greatest gender inequity oc-curred in agricultural labourer households, compared withmarket-based, subsistence farmers or non-agriculturalhouseholds [62]. Another found that farm work andhousehold chores were associated with consuming fewersnacks, and that all three (farm work, household chores,and snacks in a combined score) were significantly higherfor women than men [45]. In contrast, two studies foundno effect of being an agricultural labourer household [69]or household occupation [67] on food allocation. How-ever, if the household head was a farmer, then milk wasallocated more equitably and meat less so [69].

Land ownershipOnly Bouis and Novenario-Reese mentioned the effectof land ownership, finding that landowning householdswere less equitable with their allocation of eggs but moreequitable with fish [69].

Household size and structureThe effect of household size was also mixed. Van Esteriksuggested that the number of senior women in a house-hold would affect food allocation patterns [29], whileRizvi suggested that household size affected intakes ofindividuals, but not allocation patterns [68]. Rathnayakeand Weerahewa reported a significant positive effect ofhousehold size on mothers’ relative calorie allocations inSri Lanka [30], and a study from Pakistan also foundhigher intakes for the household head, pregnant women,and children under five years, relative to average house-hold intakes, in larger households [38]. Conversely, an-other study showed that large household size (more thaneight children) was associated with significantly highermale than female calorie adequacy [70].(Morrison J, Dulal S, Harris-Fry H, Basnet M, Sharma

N, Shrestha B, Manandhar DS, Costello A, Osrin D,Saville N: Formative qualitative research to developcommunity-based interventions addressing low birth

weight in the plains of Nepal. Working draft, in prepar-ation) reported a trend for food-related rules to be re-laxed when women returned to their parental homes,where they had fewer food restrictions. This was sup-ported by Abdullah [36], who found that women weregiven less or fewer special foods in the marital home,and so women (or adolescent, unmarried girls) receivedspecial treatment when at their parental homes. Com-paring joint and nuclear households, Ramachandran re-ported that women were allocated comparatively less innuclear households, where the women had the responsi-bility of feeding everyone; whereas, in joint householdswomen were given more because their mother-in-lawadopted the role of food planning and distribution [55].

Religion, ethnicity and casteEvidence on the effects of religion, ethnicity and castewas limited and mixed. Van Esterik [29] hypothesisedthat religion was a determinant of food allocation, par-ticularly through religious influence on food classifica-tions systems. There were no differences betweenBuddhists and Christians in food allocation [67], butBuddhist families were more equitable than Hinduhouseholds [40]. Rathnayake and Weerahewa found noeffect of ethnicity on relative calorie allocations [30],whereas Panter-Brick and Eggerman found that foodshortages caused discrimination against women duringfood shortages among Indo-Nepalese households butnot among Tibeto-Burmese households [64]. No studiesexplicitly described the effect of caste, but two studiesimplied that inequity would be greater in high castegroups [63, 71].

Distal determinantsSeasonalityTwo quantitative studies relating to seasonality foundcontradictory, non-significant and unexplained effectson intra-household food allocation. In Bangladesh,Tetens et al. found more equity in food allocation duringpeak agricultural production seasons [72], whereas inIndia Chakrabarty found less equity in cereal consump-tion in the peak season [73]. A qualitative study fromIndia found that women ate the least during plantingand harvest seasons when they were working the hardest(and working harder than men) due to a lack of appetitefrom the exhaustion [74], and a seasonal calendar fromBangladesh showed that women were allocated fewereggs and fish than men, particularly during food inse-cure months [75]. An anecdotal study suggested thatpredictable seasonal variation was unlikely to affect foodallocation patterns because households would have cop-ing strategies for predictable variations in food availabil-ity [29]. However, if this shortage overlapped withperiods of more pregnancies or more female agricultural


labour inputs, then women would have less adequate di-ets than other household members [29].

Village and regionRegional differences in intra-household food allocationwere varied. Basu et al. found no differences betweenurban and rural areas among the Lechpas ethnic groupin India [67], whereas a study from Pakistan found smallbut significant regional variation in micronutrient allo-cation [38], with higher dietary adequacy for men in cer-tain regions and lower adequacy for pregnant orlactating women in others. The authors suggested thatthis may have been a result of regional differences incultural attitudes and beliefs regarding pregnancy, butdid not describe these attitudes in detail. Harriss-Whitealso found differences in inequity between four differentvillages in India, which she hypothesised may have beendue to differences in land ownership and methods ofagricultural production [27].

DiscussionAlthough we searched for literature across South Asia,studies were mostly from Bangladesh, India, and Nepal,with few from Islamic Republic of Iran, Pakistan, and SriLanka, and none from Afghanistan, Maldives or Bhutan.We identified eighteen determinants of intra-householdfood allocation, many of which were specific to theSouth Asian context and centred on interlinked aspectsof poverty, cultural beliefs, and power. The review sug-gests that the most equitable households are low castehouseholds [63] in which women earn an income [30]and there is low educational status of the householdhead [69] (indicative of lower socioeconomic status) butthat equitable households will also be food secure [61](indicative of higher socioeconomic status).We hypothesise that these seemingly conflicting effects

could be reconciled in a non-linear relationship betweensocioeconomic status and inequity. During acute or unex-pected food shortages, households selectively invest limitedcalories in men because they have more labour opportu-nities [62, 63]. For example, recent unexpected shocks mayinclude the 2015 Nepalese earthquakes [76]. As food secur-ity increases and food shortages become more predictable,households become more equitable [65, 72, 73]. Low castehouseholds are often described as more egalitarian [71],partly because low caste men do not inherit land, [5] butalso because women have comparatively higher economiccontributions [73]. The positive effect of individuals’ rela-tive economic contributions on their shares of householdfood is also supported by evidence from the Philippines[77] and China [78]. At higher levels of socioeconomic sta-tus, inequity may increase again [27]. This is supported bythe finding that women from landowning Indian house-holds are thinner than in landless households [45].

Inequity amongst higher socioeconomic groups may becharacterised by preferential “channelling” of high sta-tus, often micronutrient-rich luxury foods such as meator dairy [9], rather than by unequal allocation of staplesthat may occur in the poorest groups [62]. If true, thischannelling could result in social rather than nutri-tional inequity, or perhaps inequity of micronutrientsrather than calorie allocation. This may explain the sur-prising negative gradient in the prevalence of anaemiain women with increasing wealth in Nepal (anaemia:32% in the lowest wealth quintile, and 49% in the mid-dle quintile) [79], despite the relatively high cost ofmicronutrients required to reduce anaemia. This in-equity may decline in households where women arehighly educated and ‘modern’, as they may have themost knowledge of dietary requirements (to counteractdiscriminatory cultural food practices) and these house-holds may be less socially conservative and restrictivetowards women. Although no studies have providedevidence to support this directly, the prevalence of an-aemia in Nepal does fall to 36% in the highest wealthquintile [79].Any socioeconomic level, dynamic intra-household

factors (such as bargaining, preferences and interper-sonal relationships) will introduce variance within thesetrends, while cultural norms and food practices (thathave wide local variation but are slow to change [40])may introduce variance and also determine the strengthof association between socioeconomic status on foodallocation.

Limitations of the study, and future workThis study benefitted from a systematic literature searchbut the results and conclusions are limited by the lack ofrecent evidence. Given the rapid changes in labour mi-gration, engagement in non-farm work, and mechanisa-tion of farm work [80], the full framework should betested with recent data. Another limitation is that moststudies came from Bangladesh, India and Nepal, so theresults may be less or not valid for other South Asiancountries that did not have any or many studies (particu-larly Afghanistan, Bhutan, Maldives, Iran, and Pakistan).Even within the results from India, Bangladesh andNepal, there is wide heterogeneity in culture, beliefs, andinstitutions, making generalisations difficult. Many re-sults arose from snowballing, indicating poor indexingof multi-disciplinary evidence, so the included studiesmay be subject to citation bias.Most papers considered only a few determinants in

their analyses and did not control for possible con-founders, so the pathways in the framework cannot bedisentangled. For example, we cannot tell whether pa-pers that tested the effects of seasonality or wealth onfood allocation would have found the same results after


controlling for household food security. Similarly, theoverlap of cultural norms, social status, income earning,bargaining power, and participation in decision-making,means that the effects of these intra-household determi-nants cannot be distinguished. We expect that theseintra-household determinants co-exist, sometimes re-inforcing and other times opposing each other.To truly understand these intra-household processes,

longitudinal mixed methods are required to examineeach possible determinant at different stages in thehousehold life cycle (adolescents, newlyweds, seniormembers, elderly), with different phase conditions (du-ring puberty, illness, menstruation, pregnancy, post-partum, and breastfeeding), at different points in thefood acquisition–preparation–distribution pathway, indifferent socioeconomic groups, in different regions andin different seasons. Given the breadth of this evidencegap, research to inform nutrition program design couldparticularly focus on the determinants of food allocationthat may be amenable to change, such as food security,women’s employment, or nutrition knowledge. Moststudies focused on energy or food quantity, so more re-search is needed on the allocation of micronutrient-richfoods [27]. Other next steps could link the evidence onfactors affecting the determinants in this framework,such as predictors of food choice, bargaining power, andfood security.

Implications of the findings: what does this mean fornutrition interventions?The findings indicate that women are disadvantaged inthe allocation of food, and that women’s nutrition out-comes could be improved through changes in intra-household food allocation patterns. In particular, pregnantwomen tend to receive lower relative allocations, and thishas important nutritional implications because nutritionduring pregnancy is associated with maternal health out-comes, intra-uterine growth retardation, child health out-comes, and is a key point in the intergenerational cycle ofundernutrition [81]. As such, interventions may need toparticularly prioritise pregnant women.By predicting the distribution of transfers at all levels

of socioeconomic status, social transfer programs couldbe designed to ensure that the intended recipients re-ceive the transfers. For example, programs deliveringtransfers in emergency contexts may need to ensure thattransfers are large enough [82], so that transfers willreach less economically productive household members.Poorer households might require additional resourcessuch as food or cash transfers to improve the nutritionalstatus of women. Low caste households may be morelikely to share these transfers equitably, and so addi-tional intervention components (such as behaviour

change communication) to ensure the transfers reachtarget recipients may only be required if the program-mer intends to disproportionately target women (orpregnant women).In contrast, transfers to high caste or better-off groups

may need to include a behaviour change component toensure that transfers reach women. Alternatively, pro-grams delivering transfers to high caste groups couldprovide lower status, less desirable goods, such as flourrather than rice [83], to ensure that transfers will bepreferentially distributed to lower status householdmembers. This leads to a wider discussion on prog-rammatic objectives, and whether programs intend tochallenge patriarchal norms to empower women and im-prove nutrition, or to work within patriarchy to achieveoptimal nutritional outcomes. Furthermore, high castebetter-off households that can already afford moremicronutrient-rich foods may not need more resourcesto improve maternal nutrition – behaviour change inter-ventions may be sufficient.Alternative, or complementary, approaches to improve

intra-household equity in food allocation may include:interventions that provide income-generating activitiesfor women, women’s groups to increase social mobilityand bargaining power or otherwise empower women, oragricultural programs to improve food security.

ConclusionsThere are many possible household-level and intra-household determinants of intra-household food alloca-tion, but evidence is out-dated and not comprehensive.Local context and variation in social hierarchies makesgeneralised conclusions difficult. Programs deliveringsocial transfers may find differential intra-household dis-tribution of transfers in different socioeconomic groups.Programs affecting determinants that are amenable tochange, such as household food security, bargainingpower, and gender-specific labour opportunities, maycause changes in intra-household food allocation patterns.

AcknowledgementsNot applicable.

FundingThis research was funded by Child Health Research Appeal Trust(CHRAT) and UKaid from Department for International Development SouthAsia Research Hub (PO 5675). The donors had no role in the design, analysis,interpretation, or preparation of the manuscript.

Availability of data and materialsNot applicable.

Authors’ contributionsHHF designed the study protocol, with inputs from NMS and AC. HHF andNS conducted the literature search, and NMS resolved any conflicts instudy selection. HHF drafted the manuscript. All authors read andapproved the final manuscript.


Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consent to participateNot applicable.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.

Author details1London School of Hygiene and Tropical Medicine, Keppel Street, LondonWC1E 7HT, UK. 2Maternal Child and Adolescent Health, World HealthOrganization, Geneva, Switzerland. 3Institute for Global Health, UniversityCollege London, 30 Guilford Street, London WC1N 1EH, UK.

Received: 13 March 2017 Accepted: 12 June 2017

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