Gender, religion, and ethnicity : A sociocultural perspective on child nutritional status in Indonesia

Summary

Malnutrition is a decisive factor that could detain individual and societal advancements. It may not only reduce individual well-being, but at macro level, could also be a burden for the national health expenditure and the labour productivity. Aside from the economic context, the sociocultural settings a person lives in may influence his/her nutritional status and their significant others. In this case, sociocultural factors operate “invisibly” by influencing people’s beliefs, attitudes, and behaviour toward food and other health inputs. Unlike the extensive efforts that many have put to understand the linkage between economic factors and nutrition, fewer works have been done to reveal the role and mechanisms by which sociocultural factors may affect child nutritional status.

Chapter 1 described the main research objective of this thesis, that is “to examine how sociocultural factors (e.g., gender, religion, and ethnicity) may influence nutritional status in childhood and adolescence (0–19 years of age)”. Indonesia, the world’s fourth largest country in terms of population, is strategically selected for the study site. In response to the main research objective, empirical Chapters 2–5 were then produced. Each chapter studied a specific theme, covering the influence of women’s empowerment (e.g., mother’s education, mother’s bargaining power, and mother’s working status) on adolescent nutritional status (10–19 years of age) in Chapter 2, the role of mother’s education in sibling inequalities (e.g., by gender, birth order, and the number of siblings) in child overweight (0–19 years of age) in Chapter 3, and the effects of maternal Ramadan fasting on the nutritional status of Muslims during childhood and adolescence (0–19 years of age) in Chapter 4, and finally, the influence of ethnicity on dietary diversity—one measure of dietary intake—of school-aged children (7–12 years of age) by gender and household socioeconomic status (SES) in Chapter 5.

Chapter 2 found a positive association between mother’s education and adolescent height-for-age Z-scores (HAZ). Regarding mother’s working status, the chapter showed that adolescents of blue-collar mothers were shorter compared to adolescents of mothers that were housewives. Most likely, the shorter stature was related to the lower food provision and supervision that mother could deliver, considering the long and typically less flexible working hours of blue-collar jobs. There was no influence of mother’s bargaining power on adolescent nutritional status. Gender inequality emerged as boys had on average a lower BMI (body mass index) for-age Z-scores (BAZ) than girls. Mother’s education compensated for boys’ lack in body mass. However, an unhealthy compensating mechanism was likely at work because boys’ consumption of high-calorie foods increased along with more years of mother’s education.

Chapter 3 found that the eldest, the youngest, and children from smaller families were more likely to be overweight. The chapter showed that the risk of being overweight increased with more years of mother’s education, especially for boys and eldest children. Further analyses showed that sons of educated mothers consumed more often high-calorie foods than did their daughters. This gender gap in consumption of high-calorie foods became greater from late childhood onwards (5–19 years of age). Referring to the Global Nutrition Transition, the chapter suggested that the openness to new diets and nutrition innovations of Indonesian educated mothers might take its form in introducing high-calorie foods rather than promoting a healthy diet and an active lifestyle to their children.

Chapter 4 found that prenatal exposure to Ramadan affected the stature of Indonesian children and adolescents. Children and adolescents of religious Muslim mothers who were prenatally exposed to Ramadan were shorter and thinner than their unexposed siblings. This lack in stature developed over time and depended on the timing of the exposure. A cautious analytical design made certain that the cause of the stature deficiency was related more to maternal Ramadan fasting rather than other factors (e.g., alternating diet and sleeping disturbance). Aside from this result, two surprising findings emerged. First, prenatal exposure to Ramadan improved the nutritional status of children and adolescents of less-religious Muslim mothers. Second, negative effects of prenatal exposure to Ramadan on HAZ arose for those who were born to non-Muslim mothers. This occurred in early childhood only (0–4 years of age) but not in later life stages. Both findings were discussed in the light of Indonesia’s context, including food price spikes during Ramadan and the timing of the annual bonuses or Tunjangan Hari Raya (THR).

Chapter 5 found that dietary patterns of school-aged children differed by ethnic group. Gendered dietary patterns emerged more in children of ethnic groups with a unilineal kinship system, i.e., the patrilineal Batak and the traditionally matrilineal Minangkabau, rather than in the bilateral Javanese. While boys and girls were similar in how frequent they consumed animal-source foods and dairy products, boys of the two unilineal ethnic groups differed in their diet to girls by consuming less often the “low-status” foods (e.g., tubers and vegetables), thus reducing their dietary diversity. The chapter also highlighted how, among Batak children with low-SES, consuming the culturally preferred but expensive animal-source foods was met at the expense of dietary diversity: a behaviour that risked their nutritional status.

Chapter 6 discussed findings of Chapters 2–5 in relation to the main research objective. This led to the following main conclusions. First, Indonesian boys were more likely to experience malnutrition than girls, specifically in BAZ. Second, the mother’s education positively influenced HAZ. However, the same indicator of women’s empowerment inflated gender inequality in BAZ by exposing boys more to overweight. Third, food culture may be differently related to dietary intake and nutritional status between and within social groups (e.g., religious and ethnic groups).

In terms of policy recommendations, this thesis suggests that alongside the traditional focus on girls, improving the nutritional status of boys should also be on policymakers’ agendas. Raising the awareness of educated mothers to better supervise the dietary intake of their sons similarly to that of their daughters is as important. Lastly, the social context of food consumption should also be considered when assessing nutritional status and designing nutrition interventions.