In some cases, respondents reported both preparation and cooking. Girls described with ease the ingredients that make up specific dishes and—unprompted—often expressed their own likes and dislikes about specific foods, suggesting a degree of agency in what they consume. Beginning with the school environment, the findings related to eating at school are important for several reasons.
First, we see that school-going girls have a problem with scheduling eating when there is no school lunch or designated lunch room. Addressing this problem would involve activities to change school policies and infrastructure in order to expand opportunities for girls to consume healthy foods during the day.
In the absence of a school meal program, a 2-pronged approach could be explored that involves: 1 the establishment of a space and a schedule routine for eating at school, and 2 creating greater awareness in families about the value of packing a healthy meal for students.
They reveal a fundamental cultural dynamic, namely the role of fathers as the source of snacks and funds for girls to purchase snacks. Although this practice undoubtedly reflects the control and flow of money within households from male household heads to women , it also represents an area of bonding between fathers and daughters. In this regard, the situation is reminiscent of a dilemma that has surfaced commonly with respect to improving breastfeeding and complementary feeding practices, namely that in many cultures men are shut out of an important social bond when their role in purchasing formula and baby bottles to feed infants or supplying infants and young children with inappropriate early complementary foods surfaced as a barrier for improved infant and young child feeding practices The current snacking pattern offers opportunities to create healthier snacks that fulfill the need for food in the many hours girls experience between eating opportunities at home on schooldays.
In addition to cost, attention to developing snacks that are not excessively high in calories is important given the value of preventing obesity in adolescent populations worldwide 21 , It also offers an opportunity that could potentially contribute to preventing iron deficiency.
The finding that one-fourth of the girls report that they avoid fish during menstruation is important. It highlights the fact that menstruation management is problematic for many school girls. If the practice of not eating fish when they are menstruating is widespread, it may be contributing to lower iron status in Bangladeshi girls, whether they are in school or out of school.
Further investigation of its ubiquity, coupled with nutrition messages to address this misperception, is clearly indicated. However, another feature of this specific finding concerning cultural knowledge is that it points to the need to address the larger problems around menstruation and menstrual hygiene that need to be followed up by intervention programs This is not to say that all beliefs are appropriate with respect to contemporary understanding of the principles of good nutrition and health.
For example, in the case of avoiding animal-source foods during menstruation, this idea is incorrect for healthy nutrition. Replacing this specific piece of cultural knowledge with knowledge that is supportive of good health should be part of nutrition BCC efforts in rural Bangladesh, not only directed to girls, but to the families in which they live.
It is a matter of how one addresses the issue as well as a commitment to sustaining respect for the complexity of local culture. This finding extends beyond an academic interest in adolescent culture. It has important implications for activities to integrate nutrition across BRAC programs.
In particular, it points to the potential of recruiting adolescents into both community and school outreach activities e. With the growing concern about obesity prevention in low- and middle-income countries, the finding that most girls have friends or acquaintances who engage in dieting is both a warning and an opportunity for BRAC nutrition activities.
From the perspectives of both public health and social well-being, preventing overweight is far preferable to managing it after it has occurred. The results of the study suggest that identifying and implementing interventions to increase socially acceptable and culturally appropriate physical activity opportunities, as well as dietary obesity prevention strategies, into BRAC programming directed to adolescents are opportunities for increasing BRAC offerings to support adolescent health and nutrition.
There are several methodologic challenges posed by small sample size. One problem is that it constrains our ability to examine intracultural diversity This is a general problem in ethnographic research, in contrast to survey research and epidemiologic analyses where the evidence for intracultural diversity is essentially built.
Moreover, analyses that seek to understand the correlates of distributions provide insights into the nature of intrapopulation differences and their implications. In qualitative studies with small samples, including the study presented here, there are no built-in safeguards against overgeneralizing. In our study, a close examination of the results provides clear evidence of the existence of intracultural diversity, including diversity in the depth and breadth of biomedical nutrition knowledge.
The results of the interviews suggest that there are substantial differences among the girls in the depth of their understanding about scientific nutrition knowledge. In future studies, these and other differences need to be more fully examined and their implications for interventions assessed so that intracultural differences in the population the interventions are intended to benefit are adequately addressed in the planning and delivery of actions.
Small sample size, coupled with the decision not to ask respondents to estimate quantities of individual foods in the h recall, preclude the possibility of characterizing nutrient intake of adolescent school girls or characterizing their diets from the perspective of nutritional adequacy. On the other hand, the nearly ubiquitous presence of animal-source foods in the girl's dietary records was a surprising finding that is unlikely to be explained by the small sample size.
The time-constrained circumstances of this study, coupled with the lack of availability of an appropriate census, meant that it was not practical to recruit respondents according to a random sampling frame. We relied on community workers to identify potential respondents and stressed to them the importance of selecting a diverse sample with respect to age, economic status, and geographic area including distance from town centers.
The sociodemographic data indicate that the sample is diverse, but we cannot rule out the possibility that the results are biased in favor of more knowledgeable respondents. Apart from the issue of representativeness of the sample for the district in our study, it is important to note that the results pertain to school-going girls in this district, and their applicability to nonschool-going adolescents or schoolgirls in other districts remains to be determined.
This is particularly important to bear in mind in the Bangladesh environment, where a girl who marries when she is of school-going age will often leave school and relocate to her husband's family home, where her agency and her access to healthy foods may be altered. The results of the study provide a starting point for BCC activities to reinforce and expand the level of general biomedical nutrition and health knowledge reflected in the interviews.
The results provide information about concepts and values that can be drawn on to structure messages, support their emotional components, and facilitate communication. The results indicate the necessity of involving other key players, especially mothers, fathers, and other family members, as well as teachers and snack purveyors, in supporting and improving girls in rural Bangladesh contexts.
The findings provide an important warning to be sensitive to father-daughter and household dynamics in BCC and other programming efforts. The results indicate that school-going girls are a potential resource for expanding knowledge about nutrition in the community. The findings clearly show that, in addition to BCC efforts, there is a need to address infrastructure barriers that affect the nutrition of school-going girls.
This is described in Chowdhury et al. Our conclusions in this paper are general recommendations for future programmatic actions rather than BRAC-specific recommendations. In our view, the results of the study demonstrate the value of including ethnographic research in implementation research. Such studies will provide a firm ground for future interventions to overcome the barriers that limit school-going girls in low- and middle-income countries from achieving their health and nutrition goals.
The contributions made by Golam Rasul Shohan, Shahanaj Shano, Mohammad Hossen Khan, and Tithi Dev, all of whom gathered the high-quality qualitative data for analysis, are greatly appreciated.
We thank Vanessa Pike for reviewing and formatting the final version of the manuscript. National Center for Biotechnology Information , U. Journal List Curr Dev Nutr v. Curr Dev Nutr. Published online Mar 8. Author information Article notes Copyright and License information Disclaimer. Chowdhury S Jalal: gro. Address correspondence to CSJ e-mail: gro.
For commercial re-use, please contact moc. This article has been cited by other articles in PMC. Abstract Background Focusing on adolescent schoolgirls in rural Bangladesh, this study aimed to describe the nutrition-relevant context required for effective intervention planning. Objectives The study was undertaken to inform a larger project to develop a replicable model for integrating nutrition activities into the multiple social programs in BRAC, a large nongovernmental service delivery organization in Bangladesh.
Methods Following an initial phase of exploratory key informant interviewing, data collection was conducted through the use of focused ethnographic methods in 2 additional phases. Results Key findings include evidence that school-going girls consume a variety of foods and have substantial knowledge about good health and nutrition practices. Keywords: adolescents, girls, nutrition, food choices, iron, ethnography, school food, snacking.
Introduction Until recently, nutrition of adolescent girls has been a neglected concern in global health, nutrition research, and programmatic action to improve nutrition 1. Methods Research design We used an ethnographic approach, as contrasted, for example with a dietary and social survey approach based on prestructured questions, because we felt that a mixed-method ethnography would produce the insights the study team needed to identify interventions within the existing BRAC framework, suggest potential new activities for BRAC, and facilitate the design and content of behavior change communication BCC activities to support integration.
Sample The study was conducted in rural areas of Rangpur District, which is situated in Rangpur Division in northern Bangladesh. Data collection After obtaining informed consent, interviews were audio recorded. Data collection was conducted with the following ethnographic modules: A module to obtain broad-based sociodemographic information about the respondent's household, including household composition, sanitation facilities, agricultural activities, and related social behaviors.
Data analysis The audio recordings of the interviews were transcribed into Bangla and translated into English by the field teams. Results Diet and food consumption patterns Foods in the diet To illustrate typical intake and consumption patterns, Table 1 presents detailed examples from 5 respondents for the h dietary recalls the full results are available on the Supplementary Materials. TABLE 1 Examples of foods eaten by adolescent girls during different times of the day: first 5 responses from the h recall survey.
Open in a separate window. Where food is consumed Turning to the spatial pattern of food consumption, we found that consumption takes place almost entirely at home, at school, or in the vicinity of the school. Beliefs and knowledge In this section, we summarize results that relate to cultural beliefs and knowledge. Sources of knowledge The acquisition of biomedical nutrition and health information involves multiple channels, of which family and school education activities are the primary sources.
Food beliefs and behaviors related to iron Anemia and behavior Traditionally, girls are expected to reduce or eliminate consumption of certain foods—including fish—during menstruation. Cultural values In this section, we present the results of our analysis of the cultural values that emerged from the in-depth interviews.
Discussion Beginning with the school environment, the findings related to eating at school are important for several reasons. Limitations There are several methodologic challenges posed by small sample size. Conclusions We want to highlight the general implications of the findings: The results of the study provide a starting point for BCC activities to reinforce and expand the level of general biomedical nutrition and health knowledge reflected in the interviews.
Notes Financial support for this research was provided by Nutrition International Author disclosures: CSJ is an employee of Nutrition International which funded the research; he declares no conflict of interest in conceptualizing and participating in the study; GP, JH, MB, and JL, no conflicts of interest.
References 1. Akhter N, Sondhya FY. Nutritional status of adolescents in Bangladesh: comparison of severe thinness status of a low—income family's adolescents between urban and rural Bangladesh.
J Educ Health Promot ; 2 Maternal and child undernutrition and overweight in low-income and middle-income countries. In other cases, research methods commit nominal fallacies, such as the Healthy Eating Index that is more accurately a U. Federal Dietary Guidance Conformance Index. Reifying these abstractions by repeatedly stating them is related to social—psychologic phenomena, such as confirmation bias, the mere exposure effect, and cognitive dissonance 3 , and thus perpetuates unscientific beliefs.
Nutrition scientists reporting research have a responsibility to be truthful so that information can be used properly by science, society, and appropriate policies to influence health. Unfortunately, many scientists are faced with perceived and real sources of conflicts of interest, which may either negatively influence science or serve as fodder for critics to wantonly dismiss well-conducted science. Financial conflicts are the most discussed, with financial ties to industries serving as the source of many expressions of concern regarding potential distortions of research reporting.
Each of these distortions was described in other ways, but white-hat bias seems predicated on researchers' beliefs that such distortions will improve human health. Instead, these distortions harm the health of science by impairing scientific integrity and damaging public trust. Several considerations may help buttress the scientific integrity of our field. Foremost may be emphasizing to scientists-in-training that science is a discipline whose sine qua non is the unwavering pursuit of truth through objective research conduct and communication.
Also, replication initiatives should be welcomed as a means of determining generalizability of results, not viewed as witch hunts. The use of meta-methods can help determine when issues exist and how the field is improving in totality. Several additional specific steps that individual scientists, institutions, and journals can take to improve nutrition science include the following.
Study registration helps ensure that the initial purpose of a study is faithfully reported in the final research output and must be taken into consideration during peer review to be of value. Thorough a priori registration of scientific studies must include the following: 1 data to be collected; 2 statements of primary and secondary endpoints; and 3 prespecified data analysis plans.
Selection of endpoints or analysis plans post hoc should be clearly stated so that results can be interpreted with appropriate caution. If multiple comparisons are not corrected, readers should be made aware of how many tests were conducted, permitting readers to evaluate the plausibility that significant effects were found by chance.
Guidelines for study types including systematic reviews, randomized controlled trials, and observational work were aggregated by the EQUATOR network 6. Instead of being viewed as bureaucratic obstacles to publishing, the guidelines should be used to help better communicate research, aid other scientists in understanding methods used, and increase the chances of replication.
Even with the faults of most human research, animal and in vitro studies are often deficient in the most elementary conditions necessary for publication of human trials, including true randomization, allocation concealment, blinding, and intent-to-treat analyses.
Great study designs, exciting results, and new understandings of the intricacies of nutrition are executed, discovered, and communicated daily.
Let us collectively celebrate the most well-conducted nutrition science and encourage those who have done due diligence in upholding the rigor on which this field is built, regardless of whether the results match our personal beliefs or favorite hypotheses.
With so many values surrounding food, including hedonic aspects, religious considerations, and cultural traditions, expecting everyone to base all of their food decisions on scientific evidence is naive at best. The authors thank Dr. John Dawson for feedback on previous drafts of this manuscript.
All authors read and approved the final manuscript. Myths, presumptions, and facts about obesity. N Engl J Med ; : — Google Scholar. Is everything we eat associated with cancer?
A systematic cookbook review. Am J Clin Nutr ; 97 : — Belief beyond the evidence: using the proposed effect of breakfast on obesity to show 2 practices that distort scientific evidence. Am J Clin Nutr ; 98 : — White hat bias: examples of its presence in obesity research and a call for renewed commitment to faithfulness in research reporting.
Int J Obes Lond ; 34 : 84 — 8. Inappropriate fiddling with statistical analyses to obtain a desirable p-value: tests to detect its presence in published literature. It is necessary to examine these within an overall framework. The attitudes model developed by Fishbein and Ajzen is presented as a framework within which such comparisons can be made. It has been shown to be useful in a variety of studies of food choice. The relative importance of different types of beliefs can be assessed within this approach by examining the relationship between individual beliefs or groups of beliefs and either attitude or behaviour.
In a number of studies sensory attributes have been found to be more important for table salt use, snack food consumption and consumption of foods contributing highly to fat in the diet. Shepherd, R.
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