RESEARCH ARTICLE Open Access

Food taboos, health beliefs, and gender:understanding household food choice andnutrition in rural TajikistanKatharine McNamara* and Elizabeth Wood

Abstract

Household nutrition is influenced by interactions between food security and local knowledge negotiated alongmultiple axes of power. Such processes are situated within political and economic systems from which structuralinequalities are reproduced at local, national, and global scales. Health beliefs and food taboos are twomanifestations that emerge within these processes that may contribute beneficial, benign, or detrimental healthoutcomes. This study explores the social dimensions of food taboos and health beliefs in rural Khatlon province,Tajikistan and their potential impact on household-level nutrition. Our analysis considers the current and historicaland political context of Tajikistan, with particular attention directed towards evolving gender roles in the wake of massout-migration of men from 1990 to the present. Considering the patrilieneal, patrilocal social system typical to Khatlon,focus group discussions were conducted with the primary decision-making groups of the household: in-married women,mothers-in-law, and men. During focus groups, participants discussed age- and gender-differentiated taboos that callfor avoidance of several foods central to the Tajik diet during sensitive periods in the life cycle when micronutrient andenergy requirements peak: infancy and early childhood (under 2 years of age), pregnancy, and lactation. Participantsdescribed dynamic and complex processes of knowledge sharing and food practices that challenge essentialistdepictions of local knowledges. Our findings are useful for exploring entaglements of gender and health that play outacross multiple spatial and temporal scales. While this study is situated in the context of nutrition andagriculture extension, we hope researchers and practitioners of diverse epistemologies will draw connections to diverseareas of inquiry and applications.

Keywords: Food taboos, Health beliefs, Gender, Nutrition, Health

BackgroundThe recognition of good nutrition as a fundamental driverfor sustained social, economic, and political developmenthas led to global efforts to eradicate malnutrition [1]. Theseefforts have aided in reducing the prevalence of malnutri-tion worldwide; however, accessing safe, nutritious food inadequate quantities continues to be a struggle for approxi-mately 815 million people across a variety of contexts, re-gardless of the GDP of their nation [2]. Spatial andtemporal patterns of food distribution are heterogeneous,causing disproportionate levels of malnutrition amongsome groups of people [3]. Intersectional approaches to

malnutrition can aid in considering the combined, complexinteractions between health and the mutually constitutingsubjectivities that contribute to vulnerability: gender, age, -ethnicity, and caste, among others [4]. In this article, weconsider vulnerable groups those whose intersecting sub-jectivities convey greater susceptibility to malnutrition andseverity of its effects (e.g., diarrhea, stunting, wasting), andface the greatest risk of long-term health consequencesdue to poor nutrition. We simultaneously explore the over-lap of vulnerability and privilege as critical for engaging di-verse agents of change who reflect a multitude of healthexperiences [5].Malnutrition takes a variety of forms and is often

expressed comorbidly alongside other health conditions.According to Soeters et al., malnutrition is “a subacute orchronic state of nutrition in which a combination of

© The Author(s). 2019 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.

* Correspondence: katiemcnamara@ufl.eduDepartment of Environmental & Global Health College of Public Health andHealth Professions, University of Florida, 1225 Center Drive, P.O. Box 100182,Gainesville, FL 32610-0182, USA

McNamara and Wood Journal of Health, Population and Nutrition (2019) 38:17 https://doi.org/10.1186/s41043-019-0170-8

varying degrees of over- or undernutrition and inflamma-tory activity have led to a change in body composition anddiminished function” ([6], p. 708). While the definitionproposed by Soeters et al. guides our conceptualization ofmalnutrition, this article places particular emphasis on theimplications of undernutrtion due to its pervasivenesswithin the study site: Khatlon Province, Tajikistan.Tajikistan faces the highest rate of undernutrition in

Central Asia with approximately 5% of children under theage of 5 years suffering from acute undernutrition (wast-ing), 30% from chronic undernutrition (stunting), and 11%from underweight [7]. Accessibility and availability of foodis most concerning in rural areas of the country, wherefood insecurity is concentrated [7]. Khatlon province, alargely rural region located in southwest Tajikistan, ishighly vulnerable to malnutrition due to the interaction ofpoverty, tough agroecological conditions, and high rates ofmale migration for work (38%) [8]. These factors are com-plicated by gender hegemonies, wherein gender expecta-tions are performed, intertwine with, and are perpetuatedwithin the broader socioecological system that dominatesubaltern masculinities and femininities [4, 9]. Ultimately,the dynamic between power, social systems, and complexfood landscapes influences how much of what kind of foodis consumed and by who.Since the 1970s, development practice has largely tar-

geted the immediate drivers of malnutrition throughnutrition-specific interventions like micro- and macronu-trient supplementation [10]. However, a growing body ofresearch demonstrates that nutrition-specific programs arenot sufficient to reach global targets as they fail to addressthe complex socioecological determinants of malnutritionrelevant at multiple scales of intervention [11, 12]. Inresponse, nutrition research and practice increasinglyemphasize the importance of the underlying determi-nants of malnutrition through nutrition-sensitive inter-ventions [13]. Within the agriculture sector, suchprograms seek to influence the availability, accessibility,and diversity of food [12]. The agriculture extension sys-tem (AES) is considered particularly well-positioned toexecute nutrition-sensitive efforts because of its closeengagement with communities and families and potentialto bridge multiple pathways to improved nutritionthrough local agro-food systems [11, 14].Tajikistan faces the challenge of developing effective

strategies for nutrition-sensitive agriculture amidst a dearthof literature relevant to its geographic and cultural context.However, in combination with cases from Uzbekistan, aneighboring country that shares some sociocultural simi-larities and shared history with Tajikistan as a former Sovietstate, this small body of work can help scholars and practi-tioners glean relevant points of entry into more compre-hensive nutrition interventions. For example, in bothUzbekistan and Tajikistan, it is common for elderly parents

to live in the home of their youngest son and his family ina multigenerational household [15, 16]. Complex relationsemerge within in this familial arrangement that are centralto the decisions made around food production, food prep-aration, and diet. While the power dynamics in this contextare diverse, the interaction of age and gender often situateyoung women and children at the low-end of intrahouse-hold hierarchies [17]. Relations between senior and juniorwomen (e.g., between mother-in-law and daughter-in-law),widowed mother and son, husband and wife, and juniorand senior men (e.g., between father and son) fluidly main-tain a matrix of interacting hierarchal structures [15]. Rela-tionships between mothers-in-law and daughters-in-laware particularly important to decision-making around foodand strongly influence household nutrition [17].Tajikistan has experienced continual demographic

changes since the late 1990s, spurred by growing rates ofmale out-migration. Today, approximately 40% of theworking-age population leave the country to pursue workabroad; The majority of migrating workers are men fromrural areas [16]. Naturally, demographic transformationsare accompanied by changes in gender relations and expec-tations at multiple levels of society. While gender in anycontext is multifaceted, encompassing a range of discursiveand performative processes by which masculinities andfemininities are (re)constructed (for example through laborand specialized knowledge) [18], rapid and ongoingchanges to national and local demographics contributeadditional complexity to local gender relations. Despite theneed for flexible research methods to capture these inter-woven interactions, categorical gender analysis—which in-terprets men and women as static groups—remainswidespread in the health literature. Nowhere is this moreapparent than in work that equates gender with womenand the fundamental linkages between men’s and women’shealth are overlooked (see [19]). Ultimately, such ap-proaches risk framing health and gender as “women’s is-sues” and essentializing men and women as either theperpetrators or victims of hierarchical dynamics, respect-ively, despite variation within these fluid subjectivities [4].A gender relations approach that is responsive to complexand changing interactions “not only within but across iden-tities and analytic categories” ([4], p. 1676), is thereforecrucial for understanding gender and health in the contextof Tajikistan.The research presented in this article builds on the find-

ings of a previous investigation that explored how Tajikintrahousehold dynamics affect the allocation of food re-sources and, ultimately, nutrition (see [17]. At the requestof local agriculture extensionists, we framed our “initialdive” into food-related decision-making practices with thepurpose of identifying recommendations to target malnu-trition through AES. Entering this investigation, we ex-pected to observe similar patterns to those documented in

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other contexts with prominent malnutrition and similarintrahousehold hierarchies. However, we found that foodtaboos and health beliefs shaped intrahousehold dietarypractices in unexpected ways—a pattern not reflected byother studies in Central Asia.In the early-to-mid 1900s, early Anthropological en-

deavors on the subject of taboos conceptualized suchpractices as irrational, pseudo-science avoidances"which, in their simplest forms, are almost as instinctiveas those of the lower animals" ([20], p. 14). Later, tabooswere reinterpreted as instrumental, rational practices thatregulate complex social systems [21]. Over the last decade,the trajectory of scholarly approaches has evolved to-wards complex, integrated visions wherein the socio-eco-logical functions of taboos are entangled with symbolismand spirituality, history and politics, and economic andenvironmental conditions [22]. In this article, we apply in-sights from contemporary inquiry into taboos (see Meyer-Rochow 2009, Golden and Comaroff 2015) in tandemwith theoretical contributions from anthropology, geog-raphy, and masculinity studies to call attention to the spe-cific ways that Tajik food taboos shape and are shapedby gendered experiences and knowledges around health.According to Meyer-Rochow (2009), the word food

taboo is used to describe the deliberate avoidance of aspecific food item "for reasons other than simple dislikefrom food preferences" ([23], p. 2). In some cases, foodtaboos protect from health hazards [24], in othersthey facilitate environmental conservation or safeguardlimited resources [22, 25]. Thus, intimate connectionsbetween food taboos and social-ecological systems punc-tuate cultural practice [17]. Food taboos can indicatespecialized knowledge of specific household membersand the responsibilities and roles attached to certainsubjectivities. In this way, both awareness and practiceof taboos may be most aparent within sub-groups mostinvolved in their preservation [18]. While food taboosare embedded within community health beliefs, the laterreflects values associated with a given activity or prac-tice. More specficially, health beliefs encompass abreadth of attitudes, perceptions, and values stemmingfrom various sources of health-related knowledge.Another distinction lies in how health beliefsemerge and are preserved within a community. Taboosinvolve the co-evolution of practices within the fabric ofsocial power structures. Health beliefs, in contrast, re-flect diverse renderings of health concepts that may beimportant at both individual and group (e.g. household,community) levels; Thus, health beliefs are not necessar-ily tied to multigenerational knowledge-sharing. Healthbeliefs and food taboos are interconnected, however,within the unique social-ecological system of the con-text from which they emerge; For example, health beliefsmay inform adaptive food restrictions. Finally, both

concepts are flexible and respond to changes in environ-mental, political, and economic configurations [23].As seen in other contexts, food taboos in Khatlon Prov-

ince may reflect intrahousehold power dynamics along theaxes of age and gender as social expectations performedthrough food practices. Building on the findings ofour earlier work, we aim to explore how food security inKhatlon Province is mediated by taboos and health beliefsthat govern dietary practices during critical points in thehuman life and along gendered subjectivities [25]. For ex-ample, young mothers and children experience increasednutrient and energy demands during pregnancy and lacta-tion, and during the first 2 years of life, respectively. Thus,food restriction at these phases life can magnify the healthimpact of seasonal scarcity, crop failure, and other distur-bances to the agro-food system on women and young chil-dren due to the interaction of social status and increaseddietary requirements during “nutrient-expensive” stages oflife [3]. Experiences of both women and men are crucialto understanding the determinants of household nutritionstatus. However, no regional study of household health hasconsidered the position of men—much less their nutri-tion knowledge and practices—beyond their role as “headof household” or as the standard next to which women'shealth status is evaluted. In light of recent gendereddemographic transformations and their role as a destabil-izing force in the Tajik household [26], such consider-ations are necessary to capture the sociocultural nuancesassociated with diet and nutrition and the multiplicity ofhealth effects incurred by all household members.This article explores and characterizes the social dim-

mensions of food taboos and health beliefs in KhatlonProvince and their potential impact on household nutri-tion by analyzing a subset of the data collected from thehousehold decision-making study described above. Weapply a gender relations approach by recognizing “genderdynamics and the circumstances under which they inter-act to influence health opportunities and constraints” ([9],p. 2); Analysis across gender categories is necessary tocapture nuance within health and nutrition experiences.Our ultimate goal is to draw linkages between local know-ledge and the evolving political, economic, and environ-mental context of Khatlon Province that came forward inthe data as central to local adaptive strategies aroundhealth. We do this by presenting taboos as dynamic, flex-ible, and in a constant state of emergence in response toongoing socioecological changes; the topics of shiftingdemographics, agricultural labor, and unspecific taboosare most salient in this respect. To our knowledge, noother studies have documented the critical role of food ta-boos and health beliefs in household nutrition and dietarypractices in the Central Asian Region. By filling the voidof locally relevant research on connections between gen-der dynamics and health, this study holds implications for

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nutrition-sensitive programs seeking to address the under-lying causes of undernutrition.

MethodsA team from the University of Florida (UF) conducted thisstudy in February 2017 in collaboration with partnersfrom the Tajikistan Agrarian University (TAU) and theFeed the Future Tajikistan Agriculture and Water Activity(TAWA) project. Prior to data collection and participantrecruitment, permission to conduct this research wasgranted by the Institutional Review Board II (IRB II) at theUniversity of Florida. UF principal investigators (PIs) wereexperienced in qualitative methods and had extensivebackground in global public health and nutrition. Re-search assistants from UF and TAU were invaluable mem-bers of the research team and worked alongside PIs fromdata collection to analysis. All research assistants from UFwere in the master’s in public health (MPH) program andwere recruited based on their previous involvement inpublic health research alongside the PIs and interest inconducting nutrition-related research abroad. TAU re-search assistants were recommended by TAU facultybased on the focus of their graduate studies in agricultureextension and communication and their familiarity withthe rural, agrarian context of Khatlon province. UF PIsprovided training in qualitative research methods to re-search assistants from both universities before fieldworkwas conducted. UF research assistants received trainingon focus group discussion (FGD) and interview methods,effective probing questions, and real-time note-takingstrategies. TAU research assistants were trained in thesame competencies with the addition of real-time oral andwritten translation and word-for-word translation andtranscription of recorded data. Together, PIs and trainedresearch assistants met with agriculture extension agentsfrom TAWA—this organization refers to extension agentsas “Extension Home Economists” (EHEs), we will use thisterminology from this point on—to deliver training onFGD facilitation and to develop a data collection strategyto implement during FGDs that would involve collabor-ation between EHEs, research assistants, and PIs. Due tothe EHEs’ familiarity with participants through their ex-tension work, it was decided that EHEs would lead theFGDs with community members while support roles werefilled by TAU research assistants (responsible for translat-ing in real-time to UF researchers and asking probingquestions) and UF research assistants and PIs (responsiblefor managing recordings, note taking, and posing probingquestions for translation to TAU research assistants).Content analysis forms the theoretical approach of this

study and was chosen deliberately for two reasons: (1)the dearth of existing literature and theories within thecontext of interest and (2) our ultimate goal of describ-ing and characterizing a phenomenon, in this case the

intrahousehold dynamics that govern food-choice andpractices in Khatlon Province. The use of content ana-lysis was crucial to our inductive approach to data ana-lysis through which codes, categories, and themes weredirectly drawn from the data [27].Prior to conducting FGDs with community members,

four key informant interviews (KIIs) were conducted withnutrition and maternal and child health specialists fromthe World Health Organization, UNICEF, German Cor-poration for International Cooperation, and a local healthclinic in Khatlon Province to provide researchers with in-formation on household food and nutrition-related prac-tices within the region. KIIs also allowed researchers togain insight into best practices for nutrition-related fieldwork in Tajikistan, specifically Khatlon Province. Partici-pants were purposively selected based on the in-countrypartners’ knowledge of organizations working on nutritionin the region. Following KIIs, the FGD instrument wastested in Yavon, a village within Khatlon province, amongmothers with children under 10 years of age. The instru-ment was revised and adjusted for cultural competency.FGDs took place in 12 villages across five districts in

Khatlon Province (Shahrtuz, Jomi, Khuroson, Sarband,and Vakhsh), which were selected due to their locationwithin USAID’s Feed the Future Zone of Influence andconnection to ongoing extension work with EHEs. In2014, TAWA EHEs established women’s groups in collab-oration with the Women Entrepreneurship for Empower-ment Project (WEEP), which seeks to provide leadershipand skill-building activities related to agriculture and nu-trition to women of reproductive age. Through their workwith the WEEP women’s groups, EHEs have built strongworking relationships and trust within those communities,making EHEs ideal facilitators of these discussions. FGDswere conducted among three target populations:in-married women, mothers-in-law, and men. These par-ticipant groups were chosen based on the patrilineal andpatrilocal social organization of Tajik households. We de-fined the participant groups according to their relationshipwith the in-married women due to her central role indiet-related decisions. “Men” refers to the husbands of thein-married women or males in the same age cohort asmen of marrying age. “Mothers-in-law” refers to mothersof the in-married women’s husband, or mothers of men ofmarrying age. Due to household hierarchies, key infor-mants strongly recommended separating these threegroups during FGDs for honest responses and to ensurefull participation of each group member in the discussion.Based on this recommendation, data from two FGDs wasexcluded from our analysis because the groups includedboth in-married women and mothers-in-law. In these twocases, EHEs were unable to separate the in-marriedwomen from their mothers-in-law without risking house-hold conflict. Thirteen homogenous FGDs were analyzed

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for the purposes of this study: seven FGDs within-married women, four with mothers-in-law, and twowith men. FGDs varied in size (from 5 to 12 participants),with fewer total male participants as compared to womendue to the high rate of male migration for work and theirsubsequent absence in many villages. Both the number ofFGDs conducted with men and the number of male par-ticipants in each FGD clearly reflect these trends.Each FGD was conducted by an EHE of matching gender

to the participants with a TAU and UF research assistantpresent. During the discussion, a TAU research assistanttranslated the discussion in real-time while one UF re-search assistant transcribed verbatim using a laptop and asecond UF research assistant took notes and asked probingquestions via the facilitator. All FGDs were recorded tocapture any lost data and were later reviewed and com-pared to the transcripts by a TAU research assistant to en-sure data quality. Due to the stigma of illiteracy, oralconsent was collected in the participants’ native language:Tajik, Uzbek, or Russian. Before initiating the discussion,TAU students or EHEs read the consent agreement aloudin the local language. The theoretical approach of thisstudy was reflected in the structure and style of the focusgroups, which were framed with open-ended questions re-lating to dietary practices and household decision-makingaround food. Targeted probing questions based on respon-dents’ comments allowed for a participant-directed discus-sion. When discussions surrounding specific infant andyoung child feeding (IYCF) practices arose in the FGDs,participants were asked to define the age at which thosepractices were exercised.Transcripts from the 13 homogenous FGDs form the

empirical basis of this study. Researchers and research as-sistants from UF carried out data analysis using theconstant comparative method where coding and analysistake place simultaneously [28]. Intercoder reliability wasstrengthened by building consensus between codersthrough intensive group discussion to develop a codingframework. Analysis was organized using Excel, in whicheach code was defined concisely. Follow-up discussionsbetween coders were continual throughout the data ana-lysis process to continually check interpretive conver-gence. Once all data were coded using QSR International’sNVivo 11 software, segments of the transcripts were re-trieved and consolidated into an Excel matrix organizedby theme, subtheme, participant group, and interpretation.From this, researchers defined recurrent themes and pat-terns. Food taboos and misconceptions emerged assub-categories nested within determinants of food choice.Following analysis, we recoded misconceptions as healthbeliefs to convey the legitimacy of local knowledge inshaping health practices. Due to the rich discussions byparticipants, researchers conducted an additional analysisof the data subset that related specifically to food taboos

and health beliefs. This allowed researchers to develop amore nuanced understanding of food taboos and healthbeliefs as they relate to nutrition in Khatlon Province.

FindingsThe findings presented here build on our previous workon the intersections of household decision-making andnutrition. Our analysis targets a subset of that data relat-ing specifically to food taboos and health beliefs, twothemes that arose as critical determinants of householddecision-making around food in the preceding work.Discussions around food taboos and health beliefs aroseorganically from an open-ended question: “Are therefoods you avoid eating? Why?” This question wasintentionally gender-neutral and probing questions,similarly, did not use gendered pronouns. Several themesand subthemes emerged that characterize food taboos inKhatlon Province according to who the taboo affects andwhen. There were also several health beliefs thatfollowed similar patterns, affecting certain individualsduring specific phases of the life cycle. Finally, a smallportion of food taboos were found to be unspecific (un-influenced by gender or age). The themes developedduring analysis are presented according to a life-cycleapproach: (1) food taboos during pregnancy, (2) healthbeliefs around breast-feeding, (3) food taboos during in-fancy and childhood, and (4) food taboos unspecific togender or stage in life.

Food taboos during pregnancyAntenatal food taboos were pervasive across participantgroups and villages. However, while men were aware of re-strictive antenatal taboos, women (in-married women andmothers-in-law) provided reasoning to detail why thosepractices were necessary. From the perspective ofin-married women and mothers-in-law, exclusion of cer-tain foods was intended to protect and support maternalhealth. For example, a mother-in-law stated, “When theyhave morning sickness they cannot eat oily foods.” Restric-tion of oily foods is practiced early in pregnancy to reducethe likelihood and severity of morning sickness. However,one mother-in-law explained that intake of oily foods maybe limited throughout pregnancy and that, in general,“pregnant women don’t eat as much oily food.”FGDs across participant groups pointed to a general re-

striction of carbohydrate consumption during pregnancy.Men voiced their awareness of this practice by noting spe-cific high-carbohydrate staple foods that are not consumedby pregnant women. The foods mentioned by men in-cluded osh (a rice dish) and mantou (dumplings). Womennoted a more comprehensive list of avoided foods, addingnoodles, bread, other baked goods. One mother-in-lawsummarized this list as “foods with carbohydrates”. Whenasked why carbohydrates are restricted, women explained

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that “if you eat these kinds of foods or meals you will havedifficulty during birth” (In-married woman). Participantsfrom women’s FGDs explained that consumption of carbo-hydrates during pregnancy leads to excessive weight-gainand a risky delivery because high gestational weight gain(GWG) “makes [the] baby very big” (mother-in law). Pista-chios and nuts, a high-fat food item, were also restrictedfrom the diet for the same reason.These food taboos may have emerged recently in

Khatlon Province due to their reported connection to rec-ommendations from local physicians. Mothers-in-law ex-plained that “[pregnant women] are told [by doctors] notto eat pistachios and nuts because they think the babieswill be fat”. This observation was supported in the FGDswith in-married women, one of who stated, “Doctors tell[pregnant women] not to eat nuts, noodles, bread, foodsrich with carbohydrates and recommend to eat more fruitsand juice.” Both quotes suggest women consider restrictionof certain foods key to physician recommendations for theprenatal diet. In-married women additionally emphasizedthe importance of fruits and vegetables to maternal dietsduring their focus groups.

Health beliefs around breastfeedingBreastfeeding practices only emerged as a topic of con-versation within women’s FGDs. Within these discus-sions, women participants reflected on the challenges ofbreastfeeding amidst breastmilk insufficiency, financialhardship, and inadequate breastfeeding promotion,awareness, and education. Insufficient milk productionwas the most commonly cited reason for early termin-ation of breastfeeding and appears to be a relativelycommon challenge among young mothers in the region.As a result of insufficient breastmilk, infants receive sup-plemental foods at an early age (before the age of6 months). For example, one in-married stated, “mybaby was four months old, and I gave him cow’s milk be-cause I didn’t have enough milk.” While some partici-pants reported that women may purchase formula whenbreastmilk is insufficient, there was an overall preferenceto supplement infant diets with animal-source milk.Women cited financial or nutritional grounds to supportthis choice. For many women and their families, formulais too expensive to consider as a breastmilk replacement.For others, animal milk is simply preferred due to theperception that it is more nutritious. As one in-marriedwoman explained: “I am not in condition to buy for-mula, but I buy cow milk for my children which may behealthier.”

Food taboos during infancy and childhoodFollowing pregnancy, food taboos prevalent during preg-nancy decline alongside emerging food taboos specific to

their new infant. Similar to antenatal taboos, food taboosduring infancy and childhood are intended to protect chil-dren during vulnerable stages in life. Across all participantgroups, infants and children were considered highly sensi-tive to gastroenteric upset based on the belief that theycannot digest foods as effectively as adults —prevention ofupset stomach was the most common reason for exclud-ing certain foods from infant’s and children’s diets.Discussions around egg avoidance departed from

the narrative of preventing gastric upset. Participantgroups also diverged in their reasons for restricting eggconsumption among young children. For example,mothers-in-law believed that “babies who didn’t starttalking, they shouldn’t eat eggs, because it will influence,they will start speaking very late." In the previous quote,the mother-in-law highlights the importance of restrict-ing egg consumption during a critical period for cogni-tive development. Since children usually begin speakingaround 18–24 months, we estimated that this participantgroup considered children under the age of 2 years mostat-risk to the perceived detrimental effects of eggs.Mothers-in-law also mentioned that “…if [children] eateggs they have the problems with their stomach." Thisrespondent connected egg taboos with the common mo-tivation to protect children from gastric upset. Men,meanwhile, diverted from both of these reasons and be-lieved that eggs should be excluded from children’s dietsbecause they are high-calorie foods.Across focus group discussions, participants differenti-

ated between appropriate and taboo foods for young chil-dren between 6 months and 2 years of age according totwo primary categories: light/ soft (considered appropri-ate) and heavy/hard foods (considered taboo). Light/softand heavy/hard foods were grouped together in our ana-lysis because some villages used the words “light” and“heavy” to describe appropriate and taboo foods, respect-ively, while “soft” and “hard” were used by others. The dif-ference in categorization of foods between villagesemerged due to linguistic variation between the studysites. Translation of Uzbek, Tajik, and Russian into Englishresulted in slightly different interpretations. However, weconsidered these words linguistic equivalents based on theparallel descriptions of each food type given by partici-pants. Participants referred to soft-textured, mild-tasting,and carbohydrate-rich foods as light/soft. Hard/heavyfoods were often diluted with water to make them morepalatable for children between 6 months and 2 years ofage. Participants described oily and carbohydrate-richstaple foods as hard/heavy. Foods within these categoriesincluded fatir (a type of bread), sambusa (a meat or vege-table filled pastry), osh (a rice dish), and mantou (a meator vegetable-filled dumpling). Again, participants statethese foods should be excluded from young children’s di-ets “because [it is] difficult to digest these meals”

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(In-married woman). One in-married women explainedthat hard/heavy foods can be introduced “starting at two,three years, but in very small amounts starting from twoyears” while another stated that, for some children, thesedietary practices continue past the age of 2 years due totaste preference or household dietary practices.Within women’s FGDs, in-married women and

mothers-in-law believed some fruits and vegetables shouldbe excluded from the diets of children under 2 years be-cause of their association with gastric upset. This practicewas affirmed by an in-married woman who stated, “Wedon’t give them tomato, cucumber, watermelon, andgrapes, because of diarrhea.” Fruits and vegetables grownunder certain conditions, inside greenhouses (accordingto in-married women) or with contaminated irrigationwater (according to mothers-in-law), were consideredmore likely to cause gastric illness in young children. Par-ticipants identified accounts from neighboring villages andpersonal experiences with sick children as their sources ofinformation. One in-married woman recounted, “Somepeople even died when they ate watermelons and melons,some people died from botulism,” a mother-in-law, mean-while, voiced the general observation that children “[havediarrhea] after they eat cucumber.” Avoidance of fruitsand vegetables in this case is protective of young children,who women in FGDs identify as most vulnerable tofood-borne illness.

Food taboos unspecific to gender or stage in lifeSome food taboos and health beliefs were reported as un-specific to gender or stage in life. Instead, unspecific foodavoidances applied to all members of the family. However,only in-married women and mothers-in-law discussed un-specific food taboos in their FGDs. Women identifiedimported food and “foods grown with chemicals”(mother-in-law) as unsafe for human consumption.Imported foods were overwelmingly viewed with dis-trust; As one in-married woman stated, “We don’t eatimported chicken. We eat our chicken from our houses,but we don’t eat imported chicken.” Others regardedimported food as "impure" and the cause of poor health.This was supported by dialog among mothers-in-law, oneof who explained, “At the time that we were pregnanteverything was pure, now it’s all Chinese and that’s whythey have a problem with health.” This quote highlightsthat consumption of imported food and the subse-quent avoidance of imported food are relatively new facetsof village life, occurring within the lifetime of themothers-in-law. Finally, this quote serves to underscorethe interaction between diet and the changing agro-foodsystem in Tajikistan. As noted with taboos during preg-nancy, breastfeeding, and early childhood, the motivationsof avoiding imported foods are tied up in protecting hu-man health.

Women participants also discussed that foods with ad-ditives and foods “grown with chemicals” should beavoided by all household members, regardless of age orgender. The reason, given by one in-married woman,was that foods like sausage may have “other bad things”added during preparation. This links back to the percep-tions of impurity and contamination discussed withregards to imported foods. Along these same lines, manywomen perceived fruits and vegetables grown with syn-thetic fertilizers or insecticides as unsafe. This was con-sidered a pervasive issue in the region, where, accordingto one in-married women, “fruits and vegetables have alot of fertilizer and chemicals.” The extent to whichthese taboos were actually practiced, however, is unclear.Fruits and vegetables were overwhelmingly perceived ashealthy by participants across all FGDs. Participantssimultaneously grappeled with the risk of consumingcontaminated vegetables. As the evidence connectingsynthetic pesticides with adverse health grows, grow-ing methods, food choices, and dietary valuesmay change to reflect what some participants de-scribed as "pure" food. For example, women partici-pants reported active efforts to reduce the risks ofeating contaminated fruit and vegetables through alter-native growing methods. As one in-married womanexplained, “Using fertilizer less, using compost insteadof chemicals. The methods for combating insects… wethink we will overcome these obstacles, like we willuse chemicals less.”

DiscussionOur findings point to several food taboos that restrictconsumption of key staple foods and nutrient-rich fruitsand vegetables for members of the Tajik household. Weknow from our previous work with this data that wheat,rice, and oil are the foundations the study population’sdiet [17]. In Khatlon Province, approximately 73% of theaverage dietary energy consumption (DEC) is providedby carbohydrates, placing carbohydrate consumption inthis region slightly above the national level and near theupper limits recommended by the WHO (71% and 75%,respectively) [29]. Wheat alone, in the form of breads,noodles, porridge, and dumplings (called mantou),accounts for more than two-thirds of total caloricintake per day [30]. That said, carbohydrates clearlyrepresent a crucial source of daily calories for thoseliving in Khatlon Province and Tajikistan as a whole.Fats and oils by comparison represent the secondmost crucial source of calories in the Tajik diet (20%of average DEC). Nevertheless, food taboos and healthbeliefs related to carbohydrates and fats/oils dominateddiscussions among in-married women, mothers-in-law,and men. Given the significance of carbohydrates,fats, and oils to the regional diet, potentially 90% of

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calories could be at risk should restrictive practicesassociated with food taboos overlap at any time. Sim-ultaneously, food-limiting practices are informed byand respond to complex socio-ecological, economic,and politically-grounded challenges. Here we expandour analysis to consider the various ways taboos andhealth beliefs are embedded within such complex sys-tems and influence community health.Our discussions suggest that carbohydrate and fat/oil--

related taboos coincide during pregnancy and earlychildhood (between 6 months and 2 years of age). Ante-natal food taboos call for the restriction of both oils/fatsand carbohydrates to reduce the likelihood of spe-cific pregnancy-related health hazards: morning sicknessand difficult delivery, respectively. Nausea and vomitingin the first trimester of pregnancy, commonly referred toas “morning sickness,” is widely experienced by womenduring pregnancy. Symptoms typically peak 6–18 weeksinto pregnancy and subside mid-way through the secondtrimester [31]. In Khatlon Province, oily and fatty foodsare considered taboo during this period of pregnancy be-cause they exacerbate morning sickness symptoms. Foodaversion during pregnancy is widely documented and es-timated to affect 50-90% of women globally [32]. Thatsaid, diet modification in response to morning sicknesssymptoms may result in inadequate intake of caloriesand nutrients if dietary changes compromise the con-sumption of local staples [33]. In the context of Khatlon,the risk of negative health outcomes brought on by foodaversion is greatest during times of food scarcity whensupplemental, non-taboo foods are more expensive orunavailable. Khatlon Province seasonally experiences foodinsecurity due to harsh winters and, increasingly, climatechange-induced crop failure [34]. Supporting pre-natal nutrition in the face of these challenges dependson sufficiency of supplemental food choices that do notagitate morning sickness symptoms.During this sensitive period of pregnancy, women also

avoid carbohydrates to suppress gestational weight gain(GWG). Participants reported that greater GWG con-tributes labor complications associated with deliveringan infant of higher birth weight. This belief, previouslyunstudied in Tajikistan, has been reported in ruralEthiopia, Nigeria, the Central African Republic, amongother contexts [3, 35, 36]. While excessive weight gainduring pregnancy can pose risks to antenatal health,moderate GWG (15–40 pounds depending on the base-line BMI of the woman) is a natural outcome of preg-nant women meeting the increased energy requirementsof pregnancy [37]. Our findings indicate that women inKhatlon Province may experience a reduced capacity toaccess and allocate sufficient food to support prenatalhealth and fetal development during the first 18 weeksof pregnancy due to the overlap of carbohydrate- and

fat-limiting taboos. Poor nutrition during this phase inpregnancy, considered the “critical window” for the de-veloping fetus due to rapid cell proliferation, impedesthe development of organs and survival of the child [38].While the restriction of oil and fat subsides with de-

creased likelihood of morning sickness, carbohydratesare considered taboo for the full duration of pregnancy.This appears connected to the nature of the health haz-ard being avoided: morning sickness is most relevantduring the first two trimesters, while the fear of deliver-ing a large baby is continual until pregnancy is complete.However, continued exclusion of carbohydrates from theprenatal diet can contribute to maternal undernutrition,which holds additional implications for child health asthe primary cause of low birth weight (LBW; weight ofunder 2500 g). In Tajikistan, maternal undernutrition isconsidered the leading driver of the country’s high neo-natal mortality rate (52 deaths per 1000 live births) [19].Low birth weight is also associated with long-term de-velopmental outcomes including subnormal growth, ill-ness, and cognitive problems [39].While the maternal and child health risks associated

with LBW are considerable, the worries voiced by partic-ipants concerning GWG, birth weight, and risky deliveryare well-founded. Evidence from public health researchsubstantiates that heavier birth weight (4000 g or more)can pose serious risks for the mother and child [38, 39].The possibility of obstetric complications is even higherfor mothers who experienced chronic malnutrition dur-ing childhood—a common occurrence in KhatlonProvince—that can lead to small stature in adulthood.Smaller placenta, uterus, and narrower pelvis accompanysmaller body composition and increase the possibility ofuterine rupture, obstructed labor, and other seriousproblems [40]. Khatlon Province (and Tajikistan as awhole) has a long history of childhood stunting which,in the last decade, has gradually declined [40, 41]. Thus,food taboos that restrict the prenatal diet may haveemerged to deal with obstetric complications brought onby early childhood malnutrition of mothers who, withrecent improvements in nutrition, give birth to propor-tionally larger infants. These findings should alert practi-tioners of the need to address women’s concerns aroundrisky delivery in order to influence food-limiting taboosduring pregnancy. Recently, significant investment hasbeen placed in increasing the number of deliveriesassisted by a skilled provider (physician, nurse, or mid-wife). According to the Demographic and Health Survey,as of 2017, 95% of births are assisted by a skilled attendantnationally (over 90% in all provinces)—a significant increasefrom 75% coverage in 2005 [42]. Skilled birth attendantsare able to respond in the case of labor complications. Inlight of the linkage between prenatal diet and women’s con-cern toward labor complications, the recent expansion of

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assisted delivery may play a role in reducing carbohydrate-limiting food practices during pregnancy.In the context of morning sickness and gestational

weight gain, dietary changes aimed to mitigate the nega-tive outcomes of nausea and vomiting during pregnancyand complications during labor, respectively. Althoughdietary modifications respond to symptoms and con-cerns that are widely experienced by mothers around theworld, changes in prenatal diet impact women's andchildren's health in context-specific ways. In the case ofTajikistan, carbohydrates and oily foods are simultan-eously avoided and central to the local diet. Dietarychanges around GWG stem from broader, structural in-equalities that are entangled with complications duringpregnancy. Upon disolution of the Former Soviet Unionin 1989, newly independent Central Asian Republicsfaced rapid degredation of social services, growth of un-employment, and transformation of agricultural sectorand, regionally, nutrition status deteriorated [43]. Re-gional differences in food security reflect the uneven ex-periences of Tajik communities in the aftermath of theSoviet crash [8]. Today, young mothers of rural KhatlonProvince, who were young children at the time of Tajikindependence, are situated at a generational turningpoint such that the nutrition status of their children willbe markedly improved compared to their own at birthand early childhood. Interestingly, our participants' con-cerns about heavier birth weight and labor complica-tions are echoed in other global contexts wherea generational divide in nutrition status between mothersand their children is striking [3, 35, 36].Women participants reported that some maternal food

avoidances are supported by recommendations from localhealth care providers. In-married women and mothers-in-law discussed the role of physician recommendationsin their interpretation of the appropriate prenatal diet ascarbohydrate-limiting. It is unclear whether a miscommu-nication occurred as the result of patients misunderstand-ing medical advice, poor communication or inappropriatemessaging around antenatal diets on the part of clinicsand physicians, or the effective communication of poormedical advice on the part of health care providers. Dueto the recent increase in skilled antenatal care coverage inKhatlon Province (87% in 2017 compared to 65% in 2005),the link between prenatal dietary recommendations andcarbohydrate restriction may indicate this is a recentphenomenon[41–43]. However, given the observation ofsimilar taboos across diverse contexts throughout theworld [23] and the extent of awareness and practice of thistaboo by men and women participants across different vil-lages in the region, it is more likely that misinterpretationof medical advice reinforces long-standing taboos or thatlong-standing taboos confirmed the communities' subse-quent interpretations of medical advice. Based on these

findings, additional clarity is needed to determine the roleof health care advice in carbohydrate-restricting taboosduring pregnancy.Like pregnant women in the first and second trimesters,

children between 6 months and 2 years of age experienceoverlapping food taboos relating to staple carbohydrates,oils, and fats. Additionally, early childhood taboos encom-pass certain fruits and vegetables and eggs. Such taboosmay restrict the diversity of foods consumed upon intro-ducing complementary foods (consumed alongside breast-milk starting at 6 months of age) or transitioning to asolid food diet (generally after 12–18 months). These ta-boos are aimed to protect children’s health by lesseningthe risk of upset stomach and foodborne illness associatedwith heavy foods and certain fruits and vegetables, re-spectively. According to participants, cucumbers, water-melons, grapes, and tomatoes are contaminated throughgrowing conditions in irrigated greenhouses. Food taboosrelated to greenhouse-grown fruits and vegetables may beindicative of broader issues relating to water, sanitation,and hygiene (WASH) as irrigation water can be a potentialsource of foodborne pathogens [44]. If community experi-ences of food and water contamination are driving earlychildhood food taboos, WASH research and interventionscould represent an entry point into child nutritionoutcomes.Egg-related taboos among children under two appear to

be preserved by mothers-in-law—who provided detailedexplanation on the topic. Awareness of egg-related tabooswas also observed by men’s groups, though their justifica-tion was not congruent with discussions withmothers-in-law. Mothers-in-law associated eggs with latelanguage acquisition and gastric irritation. According tothe literature, however, child egg consumption has a sig-nificant positive influence on child growth and develop-ment. Both an observational study and a randomizedcontrol trial have linked early introduction of eggs duringcomplementary feeding to lower rates of child stunting [44,45]. Interestingly, the random control trial also found anassociation between acute diarrhea and egg consumption;though it was unclear whether foodborne illness, allergy, orreporting bias contributed to that finding [45]. Given theoverall potential shown by recent studies for eggs to im-prove child nutrition, minimizing the effect of taboos inegg consumption during early childhood may present anavenue for addressing malnutrition in Khatlon Province.Participants reported no food taboos specific to women

after giving birth. At this point in the life cycle, health be-liefs around breastfeeding emerge regarding appropriatemethods for lactation management. A common challengereported in women’s FGDs was insufficient breastmilkproduction, the solution to which was early cessation ofexclusive breastfeeding and introduction of breastmilk re-placements. Several studies echo that mothers’ concerns

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about insufficient lactation are a key driver of early cessa-tion of exclusive breastfeeding [46, 47]. However, as ma-ternal milk production is tuned to infant consumption,frequent nursing is essential for maintaining milk produc-tion [46]. In this case, early introduction of complemen-tary foods may be exacerbating insufficient lactationdescribed by study participants. Furthermore, the intro-duction of solid foods or liquids (including water) beforethe age of 6 months increases the risk of foodborne illnessamong infants and negative health outcomes into child-hood [48]. Health beliefs regarding the safety and nutri-tional benefit of feeding animal milk versus formula as abreastmilk replacement also emerged during women’sFGDs wherein animal milk was sometimes preferred.Delayed introduction of animal milk after 1 year of age isrecommended for avoiding associated risks includingfoodborne illness, dehydration, undernutrition, develop-ment of milk allergy, and development of type 1 diabetesmellitus [49].Previous research suggests participants’ concerns

about insufficient breastmilk may be fueled by lack ofknowledge and confidence around breastfeeding or lim-ited access to information on breastfeeding [50]. In thecontext of Tajikistan, knowledge of appropriate breast-feeding practices among mothers-in-law is another likelydeterminant of breastfeeding practices. This is supportedby the literature, which suggests that senior women playa central role in determining initiation and duration ofexclusive breastfeeding. Their impact can be supportive,providing young mothers with valuable knowledge andexperience, or negative should they lack accurate know-ledge about appropriate feeding practices [51]. Given thehierarchical household relationships observed in KhatlonProvince, wherein senior mothers-in-law are respected byjunior in-married women, ensuring 6 months of exclu-sive breastfeeding will require tapping into those struc-tures to encourage positive, supportive relationships anda strong knowledge base across both senior and juniorwomen.Overwhelmingly, our findings suggest that food taboos

and health beliefs disproportionately affect those whoseintersecting identities confer greater nutritional vulner-ability within household hierarchies at specific points inthe life cycle. While taboos relating to pregnant womenand young children were pervasive in the data, somefoodtaboos were unspecific to any subpopulation within thecommunities. Interestingly, unspecific taboos onlyemerged in our discussions with women, suggesting thatwomen are the holders, managers, and preservers of thisknowledge [18]. According to women participants,imported and processed foods and fruits and vegetablesgrown under certain conditions should be avoidedbecause of the possibility of contamination by agro-chemicals that could lead to poor health among any

consumer, regardless of age or gender. Unspecific taboosare indicative of women's changing roles in agricul-ture. Though women have been involved in agriculturethroughout Tajik history in managing kitchen gardens, thefall of the Soviet Union catalyzed women’s entry into lar-ger scale, waged food production when a sudden drop inemployment triggered the rise in men migrating for work[26]. In the absence of men, women filled many tradition-ally masculine occupations, agriculture among them.Today, 75% of women in Tajikistan are involved in wagedagricultural labor [16]. A second consequence of the fallof the Soviet bloc was the sudden drop in agricultural in-puts entering former Soviet bloc countries, which plum-meted to less than one-third of their former value within3 years [52]. Food systems changed, naturally, in the handsof women. Women held generations expertise in low-inputgrowing methods and received limited access to agricul-tural inputs (e.g. fertilizers, pesticides, improved seeds,high-quality irrigation, extension services) traditionallytargeted towards men in agriculture [53, 54]. Thus, imple-mentation of low-input agriculture accompanied women’sentry into larger-scale farming as a result of necessity andfamiliarity [26].Cultural values are responsive to behavior, and vice

versa. This relationship may be heightened in the face ofextreme consequences. In the case of post-SovietTajikistan, the threat of starvation facing citizens themid-1990s demanded changes in values and practicesthroughout the food system. The emergence of unspe-cific food taboos may represent a response to emergingvalues around low-input, domestically produced foodproducts. Interestingly, similar trends have been re-ported in other countries that shared close economic tiesto Soviet Russia and experienced extreme challenges tofood security after 1991, most prominently Cuba [52].The gendered terrain of production and reproduction in

Tajikistan is dynamic and fluid. Men’s transience amidstwaves of out-migration confers instability to their iden-tities and traditional roles while women occupy new,formerly masculine spaces within and outside of thehome. It is unclear how new household relations playout in the absence of men. Our findings from focusgroups and participant observations suggest the continueddominance of the mother-in-law as the informal head ofhouse. The experience of in-married women is likely todepend heavily on her relationship with her mother-in-law [17] facilitate. Additionally, the knowledge andconfidence displayed by in-married women andmothers-in-law during FGDs brought to light clear genderdifferences in health and nutrition knowledge betweenmen, mothers-in-law, and in-married women. Whilewomen gave consistent responses regarding which foodswere taboo and why, men were often unable to providedetailed or congruent information. As suggested in

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previous studies, such health and nutrition knowledgemay be preserved by women, who pass knowledge are re-lated practices from mother to daughter and frommothers-in-law to daughters-in-law [15]. Women werealso comparatively more active during FGDs, engagingand debating with fellow participants, while men weremore hesitant in their contributions. This may reflect lackof confidence among men to contribute discussions situ-ated beyond familiar terrains of knowledge. However, dif-ferentiation along gendered knolwedges may beperpetuated by long-standing stereotypes that classify nu-trition as a “women’s issue” (separate from masculinity)and include women (while excluding men) in nutrition in-terventions [4]. The focus on women in the health sectoris blatant within large survey datasets, which house richinformation on the Tajik context while nearly excludingmen’s health statistics (For example, [41]). Researchersacross gender and health increasingly emphasize that gen-der hegemonies operate through both masculinities andfemininities and, in this way, are mutually reinforcing [4].The impact of such gender orders is further compoundedaccording to the co-experiences of age, race, class, educa-tion status, caste, among other identities. Furthermore, mi-gration of men out of Tajikistan is a destabilizing forcethat can affect household nutrition [26]. Thus, whilewomen and men may face unique health priorities at-tached to their position within the broader socioecologicalcontext of Tajikistan, women’s and men’s health are insep-arable [9].Interventions that address the gendered nature of health

knowledge and the dynamic intrahousehold arrangementsunique to Tajikistan require practitioners to actively engagewith all members of the family. Nutrition interventionsthat engage men and women can address the broadersociocultural factors that influence food taboos and healthbeliefs. A recently published review showed that men’s in-volvement in carefully planned health interventions canimprove men’s knowledge of good household nutritionpractices [55]. Additionally, the study revealed that menwho are engaged in household nutrition interventions canencourage adoption of supportive health knowledge andbehaviors by other household members. Lastly, involve-ment of men and women together in nutrition interven-tions can contribute positive changes in maritalrelationships. In the context of Tajikistan, engaging menmay serve to emotionally empower men as fathers and asdecision-makers regarding their own health status by nar-rowing the gender gap in health literacy and minimizingmen’s isolation from the family. This is particularly relevantto Tajik families that experience frequent or son for work/or son for work [55].This research represents the necessary first step to-

ward building an understanding of the potential impactof food taboos and health beliefs on household nutrition

in Tajikistan. However, several limitations must be con-sidered when interpreting these findings. First, healthbeliefs and food taboos may be associated with geo-graphic proximity to nutrition and health services andvary by the participant’s education status. The villageswere selected based on participation in the Women’sEconomic Empowerment Program (WEEP) activities,therefore FGDs were arranged to accommodate WEEPmembers who may have more in-depth knowledge ofappropriate health and nutrition practices due to theirinvolvement in the program. Also, this may contributeto the stark difference in health literacy demonstrated bymen and women. Finally, researchers faced difficultyreaching saturation within men’s FGDs due to the highrate of male migration. In some villages, men who metinclusion criteria for this study were completely absent.Therefore, the lack of men in these villages reflects thesmall sample size among this target population. Further-more, as this study represents formative work on theintersection of food taboos and nutrition in Tajikistan,continued research is necessary to further characterizeand define the nuances within this area of study. For ex-ample, investigations into nutrition in Khatlon call foradditional study around the extent to which food taboosare practiced and their impact on nutrition status viacollection of anthropometric data. Rich ethnographicdata would further illuminate the recent interactions be-tween migration, gender, and health.Despite considerable investments in nutrition educa-

tion in the last 30 years, little progress has been made inidentifying interventions that contribute to sustained,long-lasting improvements. The unclear outcomes ofthese programs may reflect the limited attention placedon addressing social norms, cultural practices, and his-toric factors that contribute to dietary practices. This re-search contributes to that effort in Tajikistan byidentifying food taboos and health beliefs that may im-pact nutrition and characterizing them within the socio-cultural context of Khatlon Province. Our study suggeststhat gender plays a significant role in shaping dietaryknowledge and practices in the study population. Similarconnections between gender and knowledge are reflected inthe findings of other scholarly works (See [18]). Analysisof gender-differentiated dietary practices and knowledgesserves to illuminate intersecting patterns of social differ-ence that contribute to various health outcomes by mov-ing beyond investigation along a man-woman binary.A gender relations approach looks closely at differentiatedcategories within gendered groups and their relationstherein, such that food practices and nutrition are concep-tualized within the contexts of power, history, environ-ment, economics, and politics in which they areembedded [9]. We hope the findings of this study are sup-portive for guiding nutrition-sensitive extension work that

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engages all members of the household within efforts toimprove nutrition. Extension programs that seek to inte-grate these findings into future work should (1) addressthe sociocultural arrangements that perpetuate food ta-boos among vulnerable members of society; (2) focus oncritical points in the life-cycle nutrition status which ismost vulnerable; (3) consider labor migration as a desta-bilizing factor within men’s, women’s, and children’s’health, and (4) address emerging unspecific food taboosand health beliefs as they relate to changing values andcultural beliefs within Tajikistan.

ConclusionIn exploring the gender dynamics of nutrition, the inter-actions between local knowledge and the evolving polit-ical, economic, and environmental context of KhatlonProvince, Tajikistan comes forward as central to localadaptive strategies around health. Food taboos andhealth beliefs are situated within and shaped by these in-tegrated processes and thus cannot be divorced fromthem. This study details how these embedded interac-tions can influence health outcomes like nutrition status.Gender and age emerged as intersecting subjectivitiesthat reproduce hierarchical familial arrangementswhile holding implications within and beyond the house-hold. As seen in other contexts, the social interactionsthrough which performance of gendered subjectivitiestakes place are saturated with power [55, 56]. Our studyfurther explored the role of intrahousehold relations inreproducing gendered knolwedge and practices aroundhealth and diet; The focus on food taboos and healthbeliefs reflect themes identified during previous re-search (see [17]). We found differential implications ofadaptive health practices and beliefs among thesubpopulations identified during focus ground discus-sions. Vulnerability (here, defined as a compara-tively higher susceptibility to malnutrition, severity of itseffects, and risk of long-term health consequences dueto poor nutrition) was concentrated among those whoseintersecting subjectivities conveyed a lower positionwithin the household social structure at specific pointsin the life cycle. These patterns may contribute immedi-ate health impacts among in-married women and chil-dren under the age of two. Among these subpopulations,increased physiological needs intersect with restrictedintake of carbohydrates, the foundation of manystaple Tajik dishes. Based on participant discussions, wepresent food taboos as dynamic, flexible, and in a con-stant state of emergence in response to ongoing socio-ecological changes; the topics of shifting demographics,agricultural labor, and unspecific taboos were most sali-ent in this respect. While men did not practice any foodrestrictions, the instability of migration inherent totheir transience in family and community life may

convey novel challenges to their health. However, men'shealth is globally understudied and men's presence asactors in nutrition-sensitive initiatives is minimal—saveas a comparative model by which to measure the statusof women. Recognizing the mutual constitution of healthacross gendered subjectivities is crucial to long-term im-provements in population wellbeing.According to the findings of this study, an increase in

agricultural production is insufficient to improvinghousehold nutrition status. Instead, it is crucial for orga-nizations to rethink the way nutrition-sensitive interven-tions are planned and implemented. While targetedappraoches to malnutrition can hold value, they can alsoimpose unintended consequences when behaviors andbeliefs are extracted from their location within adynamic socialenvironment complex. Among the oppor-tunities for change, a gender relations approach tounderstanding health can transform the systems thatseparate gendered experiences into silos. This study issituated within the context of agriculture extension ser-vices due to their potential to pursue plural strategies toimproved health where agriculture is the dominant live-lihood. Agriculture extensionists hold a unique positionat the nexus of agro-food systems, nutrition, and genderand are able to build meaningful participant-led inter-ventions through long-term relationships with commu-nities. Such involvement at the local level is necessaryfor nuanced practice-based work within complex pro-cesses described in this article. This research has appli-cations beyond extension and agriculture sectors,however, and we call on scholars and practitioners ofdiverse epistemologies to draw connections totheir many areas of inquiry.

AbbreviationsAES: Agriculture extension services; DEC: Dietary energy consumption;EHE: Extension home economist; FGD: Focus group discussion;GWG: Gestational weight gain; IPM: Integrated pest management;IYCF: Infant and young child feeding; KII: Key informant interview; LBW: Lowbirth weight; TAU: Tajikistan Agrarian University; TAWA: Tajikistan Agricultureand Water Activity; UF: University of Florida; USAID: United States Agency forInternational Development; WEEP: Women Entrepreneurship forEmpowerment Project

AcknowledgementsThis research was produced as part of the United States Agency forInternational Development (USAID) and US Government Feed the Futureproject “Integrating Gender and Nutrition within Extension and AdvisoryServices” (INGENAES) under the Leader with Associates Cooperative AgreementNo. AID-OAA-LA-14-00008. The United States Agency for InternationalDevelopment is the leading American government agency building social andeconomic prosperity together with the government and people of Tajikistan.The University of Illinois at Urbana-Champaign is the prime awardee,and partners with the University of California-Davis, the University of Florida,and Cultural Practice, LLC. www.ingenaes.illinois.eduThe research was made possible by the generous support of the Americanpeople through USAID. The contents are the responsibility of the authors anddo not necessarily reflect the views of USAID or the United States government.The authors thank the Feed the Future Tajikistan Agriculture and WaterActivity project that provided facilitators and logistical support, the Feed theFuture Tajikistan Health and Nutrition Activity project, and the Tajikistan

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Agrarian University students as well as the University of Florida Masters inPublic Health students for their contributions.

FundingThis study was supported by funding from the United States Agency forInternational Development (USAID). Funding was allocated through the Feedthe Future project “Integrating Gender and Nutrition within AgricultureExtension Services” (INGENAES).

Availability of data and materialsNot applicable.

Authors’ contributionsEW collected data using qualitative methods in the field. KM analyzed andinterpreted transcripts from focus group discussions with participants andidentified major and minor themes relating to dietary practices, food taboos,and health beliefs. KM drafted and revised the manuscript several times withsubstantial input from EW. Both KM and EW read and approved the finalmanuscript.

Ethics approval and consent to participateThis research involved human participants in focus group discussions. Assuch, researchers sought approval from the appropriate ethics committee,the University of Florida Behavioral/Non-Medical Institutional Review Board(FWA00005790). The statement of ethics approval is quoted below:“You have received IRB approval to conduct the above-listed research project.Approval of this project was granted on 1/11/2017 by IRB-02. This study isapproved as exempt because it poses minimal risk and is approvedunder the following exempt category/categories: Research involving the use ofeducational tests (cognitive, diagnostic, aptitude, achievement), survey orinterview procedures, or the observation of public behavior, so long asconfidentiality is maintained. If both of the following are true, exempt statuscannot be granted: (a) Information obtained is recorded in such a mannerthat the subject can be identified, directly or through identifiers linked to thesubject, and (b) Subject’s responses, if known outside the research, couldreasonably place the subject at risk of criminal or civil liability or be damagingto the subject’s financial standing or employability or reputation.”

Consent for publicationConsent for publication of this study is granted by the authors, KatieMcNamara and Liz Wood.

Competing interestsThe authors declare that they have no competing interests.

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

Received: 8 March 2018 Accepted: 18 March 2019

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