Date of Award

4-26-2023

Degree Type

Thesis

Degree Name

PhD in Health Sciences

First Advisor

Dr Kulsoom Ghias

Second Advisor

Dr Aziz Jiwani

Third Advisor

Dr Rubina Barolia

Department

Community Health Sciences

Abstract

Introduction: Food insecurity (FI) means people are hungry, eating a limited variety of food, or are mentally stressed about food acquisition. There are approximately forty-six million adolescents (10-19 years of age) in Pakistan but the data on their FI and diet diversity is limited. Literature suggests that globally FI is more prevalent in women compared to men and it is due to gender norms that favor men over women. Pakistan has a patriarchal society and due to limited information on Pakistani adolescents, especially boys, the gender differences in FI and diet diversity in this age are not known.
Aims and Objectives: Aim was to understand the FI, dietary diversity, and undernutrition situation in adolescents in Pakistan, and the specific objectives were mainly to estimate and compare the prevalence of adolescents’ FI, dietary diversity, undernutrition (stunting and thinness), and anemia among girls and boys of 10-19 years of age in selected rural areas of Sindh and an urban slum of Karachi. Secondly to explore the associated factors of adolescents’ FI, stunting, thinness, and anemia among girls and boys of 10-19 years of age in selected rural areas of Sindh and an urban slum of Karachi.
Methods: An explanatory sequential mixed methods study was undertaken in which two quantitative studies were followed by a qualitative study. Two cross-sectional surveys in two deprived settings (one in rural Sindh-n=799, one in an urban slum in Karachi-n=391) were undertaken. The data was collected for household FI, adolescent FI and their diet intake, socio-demographic information, height, and weight measurements, and hemoglobin estimation of adolescents. FI data was collected using Household Food Insecurity Access Scale (HFIAS) and for diet intake, the Food Frequency Questionnaire (FFQ) was used. Respondents for household FI were the mothers, for adolescent FI and diet intake, adolescents were the respondents. The data from rural and slum surveys were analyzed separately. Dietary data was converted into a score for consumption of 10 food groups and intake of at least 5/10 food groups was considered minimum dietary diversity (MDD). The frequencies and percentages of qualitative variables and means and standard deviations of quantitative variables were calculated. The frequency and percentage of adolescents consuming MDD were calculated and the difference in the proportion of girls and boys with MDD was reported. Simple and multiple Cox regression algorithm was used to generate crude and adjusted prevalence ratios (95% confidence intervals) to find the gender differences and association between factors of FI, stunting, thinness, and anemia. SPSS version 25.0 was used and a p-value of < 0.05 was considered significant. To develop a deeper understanding of the role of gender and other associated factors with FI, a qualitative study was conducted in both rural and urban slum communities. In the qualitative study, an interpretive descriptive (ID) approach was taken and semi-structured interviews of purposely selected 15 food insecure adolescents were conducted. Interviews were analyzed manually and themes and sub-themes were identified. Mixed data analysis was done through joint display analysis where qualitative findings were juxtaposed against quantitative findings and meta-inference of converging, diverging, and expanding results were displayed.
Results: Among rural adolescents, 52.6% were food insecure; (girls-26.7%, boys-78.0%; p-value < 0.01), MDD was achieved by 0.8% (girls 0.2%, boys 1.2%; p-value 0.21). In multivariable analysis, gender and household FI were the significant factors of adolescent FI. Girls were 60% less likely to be food insecure (APR 0.40, 95% CI 0.32, 0.52) compared to boys in the rural setting. The prevalence of adolescent FI was 2.34 times more in a food insecure household compared to a food secure household (95% CI 1.87, 2.95). Stunting was 31.9% (girls 35.8%, boys 28.0%), thinness 18.0% (girls 14.3%, boys 21.7%), and anemia was among 69.7% (girls 80.2%, boys 59.5%). The stunting and anemia were higher in girls (p-value < 0.01), and thinness was higher in boys (p-value < 0.01). Gender was associated with stunting and anemia where being a girl increased the prevalence of stunting and anemia compared to boys. Thinness was not different between girls and boys after adjusting for socio-demographic variables. About 46.5% of urban slum-dwelling adolescents were food insecure (girls 43.8%, boys 49.2%; p-value 0.41), 23.0% had MDD (girls 20.9%, boys 25.1%; p-value 0.32). There was no gender difference in FI and MDD in adolescents living in the slum. The regression analysis found living in food insecure households increased the adolescent FI by 2.51 times (95% CI 1.61, 3.90). Belonging to the lowest wealth status increased the prevalence of adolescent FI by 1.94 times (95% CI 1.02, 3.69). There were 20.5% of stunted boys and 20.9% of stunted girls (total 20.7%), thinness in boys was 20.5% vs. 15.3% of girls (total 17.9%), and 51.3% of boys were anemic compared to 61.2% of girls (total 56.3%). There was no difference between boys and girls for stunting, thinness, and anemia (p-value >0.05). Sharing toilets was a significant factor associated with stunting and thinness in the slum. Use of improved drinking water and late adolescence (15- 19 years) compared to young (10-14 years) were the other associated factors of thinness. At the multivariable level, none of the variables were significantly associated with anemia. Qualitative inquiry revealed six main themes 1) food availability was not related to residential areas 2) adolescents can relate the intake of a variety of diet with better health but not consume it due to poverty 3) financial crisis due to competing demands lead to FI 4) unequal intrahousehold food allocation due to gender differences 5) strategies to cope with FI included borrowing food and money, and 6) social isolation and feeling low due to FI. The findings from rural and slum areas were similar. Poverty was the commonly perceived reason for FI. It was also found at both sites that gender norms were depriving girls of food and girls at the tender adolescent age have accepted their lower social role. The quantitative and qualitative phases were integrated at the designing stage and while drawing inferences. First, survey findings were used to make a sampling frame of food insecure adolescents for semi-structured interviews. Second, prevalence ratio estimates and statistical differences were compared with the illustrative quotes of the participants through joint display analysis. The findings of mixed analysis exposed the lower prevalence of FI in rural girls and the lack of gender difference in FI is due to the perception in girls that the dietary needs of men should be prioritized over their needs. Hence it might have been underreported in the surveys. Mixed data analysis also had diverging findings for wealth status and its role in FI, the data strands converge for lower diet diversity among girls compared to boys.
Conclusion: We found FI and lower diet diversity to be prevalent in adolescents both in rural and slum areas. Mixed methods provided an insight into the intra-household food allocation and in contrast to the survey results revealed the increased vulnerability of girls towards FI and diet diversity. Our indepth exploration showed a silver lining as adolescent boys showed less acceptability towards gender norms and disagree with the practice of females eating last. To have a healthier future generation, interventions should be designed to alleviate poverty, reduce gender disparity and change gender roles at a younger age.

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