The findings from the analysis helped in reforming a framework to explain key levels, which translated into poor accessibility of iron-rich food at the community level. Figure 2 represents the framework of understanding based on the findings and reframing of our conceptual framework, including household and community environment where these women are residing, enabling us to construct the specific behaviors that promote the use of iron-rich food items. The most appropriate quotes were chosen to illustrate each subcategory.
Household environment
Individual understanding of an issue
Poor knowledge and understanding
Most of the women in the community were not aware of which food items were rich in iron content. When women were asked to name some of these items, few said green vegetables, and a small number of women thought fruits were a rich source of iron.
“We don’t know what the sources of iron (folaad) are in our food. I feel that it might be meat.”
(35-year-old female from AminJatt para)
Women belonging to the fishermen community believed that seafood is rich in iron as demonstrated by this comment:
“Fish and prawn are the main food items we use. It contains all we need. It is good enough.”
(26-year-old female from Qasmani para)
There is lack of knowledge sharing between health workers and community women. Many community women mentioned that their interactions with health workers are not very informative and effective given that the healthcare workers themselves are poorly informed about healthy food.
“We don’t know what they are trying to say, whatever they say is difficult to understand and most of the time they are in hurry. We don’t understand what they say to us. They just come and talk and fill the forms.” (45-year-old female from Dabla para)
Self-preference in consuming a diet that lacks iron content
In this community, meat is consumed at a reduced frequency. Meat is not sold regularly in the markets and is very expensive. Most of the families cannot purchase meat on a regular basis. People generally prefer fish and prawns because these items are easily available in the fishing community. Few participants mentioned having religious restrictions regarding eating meat:
“In my village, I don’t see anyone selling meat, which you are talking about. It’s all fish we like. We don’t such as the taste of meat; it has some smell, which we don’t like. I guess therefore no meat shop is here.” (36-year-old female from Wiryani Para)
A health worker shared the following:
“Our community consumes a limited variety of food in meals. If you visit their home, either you see fish or potato curry. You will also find houses where nothing is made because they don’t have money. Shops are also limited in this area. If my father has to buy good vegetables, fruits or meat, he has to go to main city, nothing here is good.” (22-year-old health worker)
Family influence
Decision maker’s decision on choice of food items
In patriarchal societies, such as Pakistan, the male members are the main decision makers at the household level. However, in our findings regarding who decides the day to day menu, we found that there is shared decision making where the women, their husbands and other family members have an equal opportunity to decide. One woman provided the following comment:
“What to cook today, we decide mutually, there is no problem with that. Sometimes, my husband says, cook this, and sometime my mother-in-law. If I have to cook something, no one has a problem.” (38-year-old female from Lalabad)
In a fishing community, the men are mostly out at sea, and women are the main decision makers for selecting food items with the limited available resources available to them.
“My husband and other male members at home are fishermen; they are at sea most of the time, so we cook whatever is available to us.” (27-year-old female from Moosani para)
Further, gender preference in serving the meal first to the male members is common in the community and perceived as a common custom.
“I always serve my husband first, the best of curry and fresh Roti, this is my duty and I follow that. I eat at the end.” (28-year-old female from Lalabad)
Poor consumption of any type of meat in diet
Consumption of meat from cattle is rare in this community, especially in the families of fishermen. The possible explanation may be embedded in the non-availability of meat shops and the lack of awareness of eating a variety of food that is essential to meet the nutritional requirement. It seems that eating seafood on daily basis or on a frequent basis has become a norm and a part of their behavior. The other factor associated with limited food choice is extreme poverty, which may affect the use of meat in the diet. One of the participants mentioned the following:
“We are poor fishermen. We cannot afford meat and things such as that to eat. We can only eat what we get free, the fish and prawn. This is only available free food for my home.”(31-year-old female from Qasmani para)
Further, there are women who highlighted that potato consumption is very high at the household level. A woman mentioned the following:
“The most frequent food item is potato at our house, it is cheap and readily available and everyone loves it.” (22-year-old female from Qasmani Para)
Influence on use of gutka
Family members who eat gutka are the major influencers in adopting this habit among women, especially after marriage.
“When I got married, I found that all my in-laws are eating it. Then, I also started it. I only took it once, I such as the taste and started using it now.” (22-year-old female from Qasmani Para)
The following information was provided by a woman:
“We shared gutka with each other. Around my home, everyone chews gutka. I don’t remember how I started it.” (46-year-old female from Milkaye Para)
The women from the fishing community mentioned that gutka consumption is increasing daily, and people are prioritizing eat it instead of healthy food. One of the participants shared the following experience:
“This thing has become an addiction currently, we can survive without meat and fruits and other things you mentioned, what you call? Yeah, iron-rich diet; we can’t survive without gutka.” (39-year-old female from Dable para)
Many women mentioned that gutka is addicting, which compels them to eat now on a regular basis. Most of the women who were of a low socioeconomic background preferred to buy gutka due to their addiction to it. One of the females who was eating gutka said the following:
“I such as to eat it all the time, I such as it! The gutka makes me feel better, it’s just 10-20Rs and cost of food is high, I such as to buy it.”
Another woman highlighted the following:
“After eating gutka, I don’t feel such as I am hungry, maybe this is the reason I am very weak. We are so poor, at least this help us.” (31-year-old female from Dabla para)
Household accessibility to iron-rich food items
Poor affordability
Most of the participants revealed that cost of meat and fruits is substantially high, which possibly explains the poor consumption of these food items. The cost is linked to the willingness to purchase meat and other iron rich food. A female community member mentioned the following:
“You are asking if we can eat meat, see, imagine the cost of meat is I think 400-500 rupees per kg or maybe more. I cannot afford this. Even if I want to eat these things, I cannot buy them. My husband is poor.” (39 year-old-female from Chasma Goth)
Another woman mentioned the following:
“Here, we have no meat shop. First, the cost of meat, and then in order to purchase it someone has to go to the main city after arranging transportation. This is too much.” (40-year-old female from Khalifa Jatt)
Community environment
Physical environment
Appeal of iron-rich food items
There are very few meat shops in the community bazars. Although meat is available in the geographical area where Pashtun and Baloch communities are located, but the fishing community has no meat shops with the exception of poultry shops, which are also very limited. A community midwife mentioned this limitation in the following statement:
“In our community, there is no meat shop. People don’t such as to eat meat; no one wants to open the shop where people are not willing to buy meat. At Eid (Eid-ul-Adha, a religious festival), people sacrifice cattle; this is the only time when we eat meat. Even, many don’t such as the taste though.” (24-year-old midwife from Shaikh para)
Furthermore, a community woman provided the following information:
“We don’t such as to eat meat, so no shop is here. What will that person do if no one will buy? Additionally, meat is expensive, it’s just not we don’t want to eat. This is also a reason.” (45-year-old female from Moosani para)
Availability of iron-rich food items
Food prices
Many of the shopkeepers link the poor consumption of different food items with cost and highlighted that community has limited purchasing power to buy expensive food items, such as meat and fruits, which ultimately affect the consumption of a variety of foods.
“See, meat is 800-900 Rupees per kg, and mutton is even more expensive. What do you think, can these people afford it? No! They cannot. Look at the cost of Mangoes, 120 to 200 Rupees per kg. No can buy these expensive items if they have many members at home.” (A fruit cart owner at Jabal))
“Poor people cannot even afford to buy wheat and rice; they are struggling to buy them. No one came to me for monthly ration, rather day to day small quantity only.” (Grocery shopkeeper in Moosani para)
Poor availability
Meat shops are scarce in the fishing community. If someone must buy meat, the only option is the main city, as mentioned by one of the shopkeepers:
“There is no meat shop in this whole village. No one wants to sell it because the market is not good here. See, I have only a few chickens available; very rarely someone comes to buy it also. Meat has no market.” (Poultry shop in Moosani para)
Social environment
Peer pressure to consume a monotonous diet
Woman from the fishing community are mostly reliant on a monotonous diet. This behavior is adopted from other community members and relatives who have been practicing it for past years. A similar experience was reiterated by one of the community health workers, who has been working on improving maternal and child health in the area for last 5 years.
“It is very difficult to communicate to our people to eat healthy diet. They can only eat meat in the form of fish and prawns, which are free to them if their husband is a fisherman. They cannot afford beef or mutton; this is very expensive for them. Few only eat once in a year – at the occasion of Eid-ul-Adha.” (21-year-old community health worker from Sache Dino)
Findings from market survey
The availability of meat shops is very scarce. For a population of approximately 42,000 people, only 3 shops were available, and the availability of meat was only 41.7% at the time of the observation visits, and mutton and lamb meat was not available at all. Specifically, regarding poultry meat, 9 shops where identified, and 63.9% of the time poultry meat was available at the shops during observation visits. We also found 8 different fruits carts in the community. Most of them are static in location, and only two were relocated on a daily basis. The availability of fruits was very erratic and subject to season. The most frequently available fruit was watermelon (84.4%), and the remainder of the fruits, which are rich source of iron, exhibited varied availability from 0% for prunes to 65.6% for apples. Specifically, regarding vegetable carts, which are mostly mobile, only spinach was found to be available on 63.6% of the time during observation visits, whereas other iron-rich vegetables were marginally available. Grocery shops are readily available in the community. Chickpea and lentils are available 82.7% and 90.4% of the time, respectively. Eggs were available 92.3% of the time. However, the shopkeeper mentioned that they did not replenish the stock for at least one month with the exception of eggs. Further, the availability of red beans was very limited (3.8%) as these beans were only available at one shop during two observations. We also observed that gutka shops are readily available in the community.