HEALTHY MOTHER, HEALTHY BABY ACTIVITY
GENDER GAPS ASSESSMENT
KHATLON, TAJIKISTAN
Data Collected: June-July 2021 Submission: Aug 29, 2021
This document was produced for review by the United States Agency for International Development Tajikistan Mission (USAID/Tajikistan). 1 1. SUMMARY
Program Name: Healthy Mother, Healthy Baby Activity Name of Report: HMHB GENDER GAPS ASSESSMENT Name of Prime Abt Associates Implementing Partner: 72011520C00003 [Contract/Agreement] No:
Name of Subcontractors: Dimagi, Changeable Khatlon Province Geographic Coverage Districts: J. Balkhi, Jaihun, A. Jomi, Khuroson, Levakant, N. Khusrav, (districts) Qabodiyon, and Yovon Reporting Period: June - July 2021
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2. ACRONYMS
COVID-19 Coronavirus-19 DC District Coordinators FGD Focus Group Discussions FTF Feed the Future GBV Gender-based Violence GOT Government of Tajikistan HLSC Healthy Lifestyle Centre HMHB Healthy Mother Healthy Baby IEC information, education, communication KII Key Informant Interviews MCH Maternal and Child Health PHC Primary Healthcare Centers SMART Specific, Measurable, Achievable, Relevant, and Time-bound THNA Tajikistan Healthy Nutrition Activity USAID U.S. Agency for International Development VIP Ventilated improved pit latrines WASH Water, Sanitation, and Hygiene PWD People with disabilities CWFA Committee on Women and Family Affairs WRC Women Recourse Centre
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TABLE OF CONTENTS
1. SUMMARY ...... 2
2. ACRONYMS ...... 3
3. ACKNOWLEDGEMENTS ...... 5
4. OBJECTIVE ...... 6
5. GENDER ASSESSMENT METHODOLOGY ...... 6
6. TAJIKISTAN HEALTH AND NUTRITION ACTIVITY ...... 9
7. DATA ANALYSIS ...... 11 7.1 Men and Women’s Access to Healthcare Services ...... 11 7.2 Men and Women’s Access to Nutrition Services and Information ...... 15 7.3 Men and Women’s Access to WASH ...... 17 7.4 Women’s Economic Empowerment ...... 18 7.5 Gender Relationships and Power Dynamics ...... 21 7.6 Key Influencers, Sources of Information, and Media Preferences ...... 23 7.7 Focus Group Discussions ...... 26 7.8 Key Partner and Project Capacity to Deliver Gender Responsive Services ...... 28
8. CONCLUSIONS ...... 28
9. RECOMMENDATIONS ...... 31
10. ANNEXES ...... 33 10.1 Annex I: Case Studies ...... 33 10.2 Annex II: Data Collection Questionnaire ...... 34 10.3 Annex III: Tables ...... 40 10.4 Annex IV: List of Literature ...... 43
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3. ACKNOWLEDGEMENTS
The United States Agency for International Development (USAID) Healthy Mother, Healthy Baby (HMHB) Activity would like to acknowledge all who supported this 2021 Gender Gaps Assessment in Khatlon, Tajikistan.
We would like to thank USAID/Tajikistan Mission for the financial support to make the assessment possible. We would like to appreciate the active partnership with the Government of Tajikistan, especially the leadership in Khatlon inclusive of District’s Department Committee of Women and Family Affairs, Heads of the Department of Religion, Regulation of Local Traditions and Ceremonies of the District’s Executive Body, Heads of Department of Work with Youth and Sport, Healthy Life Style Centres, Local jamoat’s representatives, doctors and nurses from the local District clinics, and active community members.
HMHB also recognizes the lead consultant, Ms. Shahlo Shoeva, for technical expertise in tool development, data collection, analysis and report writing. We would also like to provide recognition to the Abt Associate gender expert, Ms. Abigail Donner, and Abt’s editors, Ms. Leah Quin and Ms. Rachel Peniston.
Last, with deep gratitude, we would like to thank the HMHB in-country Tajik team, especially the District Coordinators, who assisted with data collection.
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4. OBJECTIVE
Gender equality and women’s empowerment are fundamental components of human rights that are key to effective and sustainable development outcomes. For societies to thrive, women and girls must have equitable and safe access to resources including education, healthcare, capital, technology, land, and markets. They must also have equal access to opportunities that will enable them to become business owners, peace builders, and leaders. Equality between women, girls, men, and boys improves the quality of life for everyone.
Gender equality is not just a woman’s issue; it is also inextricably linked to public health. If women and girls are not valued, cared for, or given equal access to health, overall health objectives cannot be met.
The objective of this assessment is to evaluate the gender-related components of the Healthy Mother, Healthy Baby (HMHB) Activity, identify gaps, and provide recommendations on mainstreaming gender throughout the activity in alignment with the USAID Gender Equality and Women’s Empowerment Policy (2020).
Abt Associates conducted this gender analysis on the HMHB Activity and documented findings in this report, in which gaps were identified and recommendations provided. The report analyzes qualitative data pertaining to Abt Associate’s gender dimensions and areas of operation, with a focus on health, nutrition, economic empowerment, and water, sanitation, and hygiene (WASH) sectors. The findings will help ensure alignment with the six USAID Gender Analysis Domains: 1. Access, 2. Knowledge, Beliefs and Perception, 3. Practices and Participation, 4. Time and Space, 5. Legal Rights and Status, and 6. Power and Decision Making and the USAID Gender Equality and Women’s Empowerment Policy throughout the course of implementation of HMHB.
5. GENDER ASSESSMENT METHODOLOGY
Assessment Methodology
The assessment encompassed qualitative and quantitative data collection methods such as Focus Group Discussions (FGD) among implementing partners and other key actors in four target districts. It also covered Key Informant Interviews (KII) in another four target districts. Respondents were asked questions about the community as a whole and not asked about their personal opinions (for example, instead of asking “do you personally think women are equal to men”, respondents were asked “does your community believe that women are equal to men?”). As such, respondents answered based on their perceptions of other people in their community and how they think as a whole, rather than expressing their only on their own personal beliefs. Furthermore, four Case Studies were captured to highlight specific perspectives of two women and two men from the HMHB target districts.
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Table 1. Number of FGD Participants per District
District Total Number of female Number of participants male participants Khuroson 8 4 4 J. Balkhi 10 6 4 Yovon 7 4 3 Qabodiyon 6 3 3 Total 31 17 14
Table 2. Number of KII Participants per District
District Total Number of female Number of male participants participants Jomi 2 0 2 Levakant 8 2 6 Nosiri Khisrav 6 5 1 Jaihun 5 2 3 Total 21 9 12
Implementing partners and community members from four districts held FGDs—J. Balkhi, Khuroson, Yovon, and Qabodiyon with 31 respondents.
Researchers conducted seven interviews with 21 key informants in A. Jomi, Levakant, Nosiri Khisrav, and Jaihun districts. Key informants refer to individuals who had insight into the health care sector, including nutrition services, economic empowerment, WASH, and other domains in their targeted communities. The key informants included:
• Implementing partners • Local community leaders • Community members (both men and women) • District officials aware of the Activity • Health providers • Women committee members • Religious committee members • Youth committees engaged in project planning and implementation
These activities took place in locations that protected the confidentiality and safety of participants. Researchers conducted the assessment within the community (i.e., household, health facilities, and jamoat offices (municipality office, each district has their such offices) and followed necessary precautions to prevent COVID-19 spread. We asked all respondents to provide their informed consent in writing on USAID consent forms.
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Capacity Building for District Coordinators
Within the framework of the HMHB Gender Assessment, a three-hour data collection awareness training for District Coordinators (DC) was conducted. The training aimed to enhance participants’ knowledge of the methodology and tools for conducting the Gender Assessment. Before each KII, DCs were provided guidance and practical tips on how to effectively conduct interviews, including the guidelines listed below:
• Speak simple language and avoid using scientific and academic terminology • If something is not clear, ask for clarification • Manage the interview time, but be polite • Do not argue with the respondent • If the respondent wants to stop the interview at any stage of the conversation, do not insist upon continuing and respect his/her right to stop • At the end of the interview, thank the respondent for their participation and explain how important his/her opinion is for the assessment and further work
Data Collection Tools
The Gender Assessment exercise consisted of several sub-activities, including:
• General conversations with community members, implementing partners, local leaders, and district officials who are directly involved in the project • Meetings with representatives of local authorities working on issues of women and gender equality • Conversations with four respondents (two women and two men) who shared their experience on access to health care, nutrition, WASH, economic opportunities, resources, and information, as well as their gender experience and challenges • Collection of respondents’ suggestions and recommendations on how to improve health care, nutrition, economic opportunities, WASH, and access to information and resources on creating a gender-friendly environment in their communities • Identification of the population’s preferred channels of communication and trusted sources of information, including media preferences • Identification of key influences and most respected community leaders who can influence the behavior of the target group
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Data Analysis
Researchers thoroughly analyzed the information and data collected through the FGDs, KIIs, literature reviews, and general conversations with key actors. This analysis enabled better understanding of the current gender relationship dynamics and revealed existing gender gaps, including the needs, concerns, and experiences of both women and men. More specifically, the assessment answered the following questions:
• What are the challenges around health care, nutrition, economic opportunities, and WASH? • What are perceptions and beliefs about health care, nutrition, economic empowerment, and WASH practices? • What is key partners’ capacity, skills, and practices, and how can HMHB deliver gender-responsive services? • How can HMHB identify gender capacity needs and gaps of project staff and stakeholders? • How can HMHB inform the curriculum and design training content for gender- responsive implementation, monitoring, and evaluation—including SMART indicators—to enable gender-responsive monitoring and evaluation of HMHB success? • How can HMHB prepare a comprehensive list of resources, including publications, reports, websites on gender equality and women’s empowerment, and USAID gender policy materials, and put them all to use throughout project implementation?
6. TAJIKISTAN HEALTH AND NUTRITION ACTIVITY
USAID has comprehensively invested in Khatlon as part of USG priority to support Khatlon region. From 2016-2020, USAID-funded Tajikistan Health and Nutrition Activity (THNA) which was implemented in 12 targeted districts of Khatlon, which are all Feed the Future (FTF) zones of influence. THNA strengthened its targeted approach to women by enhancing women’s role in creating opportunities for livelihoods and savings through agriculture-related activities and by focusing on men as purchasers of nutrient-rich food. HMHB is the USAID follow-on investment of THNA and builds off its foundation thus important to consider what had previously been accomplished.
THNA changed its approach in addressing nutrition-specific gender issues by targeting women of reproductive age, who are at high risk of giving birth to malnourished infants if the woman suffers from micronutrient deficiencies. Activity reports revealed that both men and women have the power to influence the behavior and mindset of their communities; identifying roles and responsibilities of both men and women enabled the Activity to implement gender-sensitive approaches in agricultural, nutrition, sanitation, and health activities.
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Through agricultural educational activities, THNA focused on strengthening the link between women’s empowerment and nutrition. Through trainings, the Activity enabled women to make meaningful contributions in food collection, processing, preservation, and storage. For example, encouraging women to pursue poultry farming enabled them to stay home and look after chickens while continuing to look after their children; they could earn money by selling eggs and chickens and use them to provide food for their own family. This resulted not only in increased nutrients and protein in the household diets but also increased families’ incomes. Women were eager for this type of support, especially female-heads-of-household. Moreover, the extra earnings allowed women to purchase necessary non-food items that they could otherwise not afford.
THNA's other gender activity was the construction of eight-seat ventilated improved pit latrines (VIP) latrines for male and female students with separate entrances/exits.
The Activity also trained 180 peer educators (sixty percent of whom were girls) on issues related to family budgeting and hygiene. Later, the peer educators conducted educational sessions for 3,870 students (forty-nine percent were girls) on family budgeting and hygiene.
THNA reported that 12 health fairs and events were conducted at the community level. The goal of the events were to provide health services to women and children living in the most remote communities. The total number of beneficiaries reached was 653 people (sixty-nine percent of whom were women, and thirty-one percent were children).
THNA made additional efforts to promote gender equality by supporting peer support groups for mothers-in-law.1 The Activity also continued encouraging and engaging men as equal partners in the struggle for gender equality by creating peer support groups around maternal and child health (MCH) issues. Male family members began promoting exclusive breastfeeding for the first six months of life—recommended by the World Health Organization (WHO) to achieve optimal growth, development, and health—through these peer support groups and other initiatives.
Reviewing the THNA reports demonstrated that activities were generally gender mainstreamed. More specifically, the Activity addressed gender needs and constraints in 12 target districts by ensuring fair distribution of resources and equal participation of women and men. As for the gender implications of VIP latrines, latrines benefit school
1 Author’s note: In general, men and mothers-in-law make considerable decisions about the health care- seeking behaviors of women with young children. THNA focused on individuals and families by supporting direct, targeted interventions, such as individual counseling and peer support groups, which facilitated transformative learning. THNA incorporated gender-sensitive approaches into its nutrition-specific interventions, in line with the nutrition strategy and in accordance with the results of the nutrition behavior study. It strived to strengthen its work with mothers-in-laws as family decision-makers through peer support groups. They were provided educational sessions on home budgeting and hygiene. These encouraging opportunities focused for improving of livelihoods and savings through the agricultural sector and by focusing on mothers in law and men as household providers and the purchasers of nutrient-rich food.
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students, especially girls. However, there was no evidence that VIP latrines improved girls’ school attendance rate and/or on the impacts.
Gender mainstreaming in some THNA activities were linked to quantitative indicators; for instance, it demonstrably increased men and women’s participation in project activities and events. While this represents a positive change, increased participation levels do not comprehensively address the root causes of gender inequality.
Empowering both women and men through capacity building activities leads to transformative changes that contribute to gender equality. To this end, the Activity conducted several capacity buildings trainings on MCH and hygiene issues for project beneficiaries, including men, women, boys, and girls (although THNA did not report that they conducted any gender-specific training for target groups).
7. DATA ANALYSIS
Researchers collected data in the field from July 5-19 in eight HMHB Activity target districts of Khatlon province. They also conducted four FGDs in J. Balkhi, Khuroson, Yovon, and Qabodiyon districts, and conducted KIIs in the Levakant, Nosiri, Khisrav, Jaihun, and A. Jomi districts of Khatlon province. Overall 52 people responded, including 21 KII respondents (of whom nine were women, and 12 were men). Of the 31 FGD respondents, 17 were women and 14 were men. The respondents included officials from the Committee of Women and Family Affairs and the Department for Youth and Sports, as well as religious figures, members of Healthy Lifestyle Centers, health workers, local community leaders, and active women2.
7.1 Men and Women’s Access to Healthcare Services
Health Sector
Both women and men have equal access to healthcare services in Khatlon. However, there are other challenges that affect access, including long distances, costly health services, and understaffed health facilities. The challenges frequently affect women since they are responsible for ensuring that family members (both older adults and children) receive timely medical attention and healthcare services. In many Tajik families, women are still dependent on husbands and mothers in law including for permission to access healthcare.
Fifty-one percent of KII respondents informed researchers that both men and women have equal access to healthcare—meaning that in most families, both men and women regularly visit clinics to see doctors. According to respondents from A. Jomi and Nosiri
2 Author’s note: Active women refers to women who are very active (energetic) in community life and participating in different community and local governmental events, aware of many news, and at the same time they inform the other members of community on any news, changes, important and useful information that people in their area should know.
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Khisrav districts, there are functioning Primary Healthcare Centers (PHC) that house health worker staff and deliver health services to remote villages. The respondents also mentioned that families who have children under the age of three regularly undergo medical check-ups and receive vaccinations because these parents feel obligated to seek out care for their youngest children, they are also more likely than other families to seek out care for themselves and their older children.
Forty-seven percent of respondents in Jaihun, A. Jomi, Nosiri Khisrav, and Levakant districts said that both men and women have access to health care services, but there are some families that do not regularly visit clinics, doctors, or PHC due to associated costs. More specifically, they mentioned that medical tests—like blood tests for pregnant women—are often too expensive, making it difficult for some families to afford regular visits to the doctor. Two of the five respondents from Nosiri Khisrav district mentioned that to take blood tests, women from remote villages must travel to Shahrtus district center (16 km distance) where the nearest clinic is located. The respondents also identified that there is a shortage of health workers in Nosiri Khisrav district.
Men and women do not have enough information about the overall importance of health and are not aware of dangerous symptoms during pregnancy, the risks of becoming malnourished during pregnancy, or the importance of nutrition for pregnant women. Moreover, some families do not recognize the seriousness about health conditions of their family members and/or delay seeking care from lack of financial means.
Sometimes, families opt for non-allopathic treatments that can lead to serious health consequences. Fewer than two percent of respondents reported that they seek assistance from local traditional healers because they do not trust the modern healthcare system. These people tended to be older women. They reported that it is not necessary to take most medications prescribed by doctors, and some even felt that allopathic medicines may have negative side effects for young children. Instead, they reported that when they brought children with a sore throat to a traditional healer, their condition improved even after just one visit. From a cost perspective, traditional healers may appeal to low-income families because unlike doctors, they do not accept payment in money, and accept payment in goods such as flour, oil, or other food items instead.
Sixty-nine percent of respondents highlighted that usually women—particularly mothers—are the ones who take their children to healthcare facilities. They also explained that the men often accompany their pregnant wives during visits to health facilities. Ten percent mentioned that mothers-in law accompany their daughters-in law if the couple lives with their in-laws. Some respondents pointed out that women ask permission from husbands if they need to take a child to the doctor since the men are considered head of the household and usually pay for the doctors’ fee for treatment. Twenty-one percent of respondents said that they consult with their husbands and sometimes visit health facilities together. There are also few families in which both spouses have undergone higher education and live independently. In Nosiri Khisrav district, respondents mentioned cases in which mothers-in-law did not permit vaccination of small
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children and only allowed children to get vaccinated after health workers convinced them that vaccines are healthy and safe.
Seventy-six percent of respondents pointed out that men, especially younger men, would like to learn more about overall health, pregnancy, and childbirth. They would especially like to know how to prevent risks during pregnancy and childbirth and are interested in preventing illnesses that may affect both mother and baby.
Fourteen percent of respondents claimed that it is not necessary for men to know about health, pregnancy, or childbirth. They believe that the mothers-in-law should help women during pregnancy and take care of young children.
Almost eighty-eight percent of respondents said that childbirth should take place in the hospital and that men should accompany their wives to the delivery unit. They noted that hospitals have all the necessary facilities and equipment to help both woman and child during the delivery process and after the child is born. They also mentioned that hospitals are safe because doctors and midwives are there to regularly check and care for both mother and child and respond quickly in case of an emergency.
In response to the question of men’s participation in their partner’s childbirth, some spouses indicated that they preferred to be beside their wives during the delivery of their child. Due to traditional culture, religion, and local customs, some men felt that childbirth was uncomfortable to witness and did not want to be present. Many male respondents said that men’s presence during childbirth is not acceptable in more traditional families. Some wives also indicated that they did not want their husband to participate. Some people felt that men’s presence during childbirth could interfere with health providers’ important work, and for this reason some men opted not to participate at all. Nearly thirty-five percent of respondents said that they think it is important for men to take part in the process and support their wives, but feel that they should discuss it with their wife and doctors in advance. Some respondents pointed out that such practices could be acceptable in modern and educated families, but not in rural areas.
Gender-based Violence
All respondents said that they are aware of gender-based violence (GBV), domestic violence, and different types of violence. The information respondents receive comes mainly from television (they mentioned short video-clips from the Prevention of Domestic Violence implemented by GOPA project, specifically). Some respondents said that they participated in round tables and other local events on preventing domestic violence, and many mentioned that civil society organizations and donors disseminate lots of materials related to GBV.
Respondents expressed that no one, especially women and children, should have to suffer physical violence from other family members, nothing that perpetrators were often men. Respondents stressed that domestic violence occurs frequently because of low education levels, lack of information about consequences of violence, and lack of awareness of law
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preventing domestic violence in Tajikistan. Respondents stressed that domestic violence is a common reason for many family breakups and that it has negative effects on families, especially women and children.
Thirty-seven percent of respondents said that domestic violence happens because of economic difficulties. Sixty-three percent said that many victims of violence are women while the perpetrators are often men. There are some cases in Nosiri Khisrav district, however, where mothers-in-law inflicted psychological abuse upon their daughters-in-law. Some respondents mentioned that violence is not a method for settling family disputes, and others explained that systematic physical violence against women can lead to suicide3. Respondents also stressed that women do not know where to seek support, and even in cases where they do, villagers in their community discourage them from pursuing help because they feel that she will bring shame upon her family by raising internal domestic issues in a public forum. One respondent shared an anecdote that illustrated this point; in one case, a woman who had suffered domestic violence tried to file a complaint with local police, but police officers—mostly men—refused to take the case. They told her that she was casting shame upon her family by complaining about her husband and forced her to withdraw her complaint. Unfortunately, many women in Tajikistan have suffered domestic violence so frequently that they accept it as normal.
Seventy-two percent of respondents said that domestic violence is perceived negatively by women, the household, and the larger community. Respondents said that violence negatively effects women’s health and children’s psychology. Respondents also said that the use of violence can become so habitual that both the perpetrator and the victim become accustomed to it and accept it as a normal behavior in spousal relationships. In Jaihun district, respondents said one family in their village (jamoat Qumsangir) there is a 74-year-old man who has perpetrated violence against his 72-year-old wife for many years. His sons also abuse their wives. Respondents explained that it is extremely difficult to intervene because the women do not advocate or seek support for themselves, and because this is a well-known family in the village. Unfortunately, there are several reasons that prevent women from seeking support; many of them do not know where to go or who to turn to, and there are not many resources available to them locally. Another factor is that in many cases, even if a woman files a complaint with law enforcement, police inspectors will force her to withdraw her complaints and cast shame on her for publicizing domestic problems.
Disability
When respondents were asked if they know anyone in their community who has a physical or mental disability, eighty-two percent responded yes. Interestingly, eighteen percent of respondents said that even though they were aware that there are people with disabilities living in their communities, nobody knows the real number of people with disabilities. The
3 Author’s Note: In Tajikistan, over the last seven years the issue of suicide of women with their children has happened in different regions. In the majority of cases, the reason includes physical violence by a male family member. In one KII, two men mentioned it in response to a question regarding “whether physical violence (beating a wife) solving family issues”.
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respondents stressed that the community helps and supports people living with disabilities, especially during big events and holidays.
During Eid, local authorities, religious representatives, local entrepreneurs, and migrants provide basic food and clothes to people with disabilities and their families. Local entrepreneurs even provide wheelchairs and crutches to some people with physical disabilities. Respondents also noted that people with disabilities sometimes receive medical care and services free of charge.
The community accepts and cares for people with disabilities. Children with disabilities attend school and participate equally in school events and contests. One girl with a physical disability in A. Jomi even won a contest on reading a book called Foroughi Subhi Donoi-kitob ast. As a prize, she received a substantial monetary reward from the local administration.
In response to the question “what should be done to support people with disabilities in your community?”, forty percent of respondents said that they would like to get accurate information on the exact number of people with disabilities in their community. With that data, they could conduct a quantitative and qualitative needs assessment that would help illuminate the kind of support that should be provided to these families. Twenty-seven percent of respondents said that it would be useful to open a small workshop that would employee people with disabilities so they can generate income. Thirty-three percent of respondents believed that people with disabilities should be included in the community’s daily life and events as equal members.
7.2 Men and Women’s Access to Nutrition Services and Information
Women play a major role in providing family food services and are more involved in managing family diets than men.
Sixty-one percent of respondents noted that both men and women buy food in markets and shops. If husbands have migrated (employment migration of Tajik men to Russia and Kazakhstan is very high), are absent or divorced, or if the woman is a widow, then women take over the responsibility for purchasing food items according to thirty-nine percent of male/female respondents. Respondents explained that women always buy different types of food and consider vitamins, calories, and nutrients when shopping because they tend to be more informed about healthy and nutritious foods. Men usually buy basic foods like flour, oil, rice, sugar, and other similar staples. Women in Tajikistan are more involved than men in nutrition capacity building activities and awareness raising campaigns, and are therefore better aware of the importance of providing their family with a healthy diet and nutritious food.
Eighty-six percent of respondents observed that both men and women decided together what foods to buy for family meals. Fourteen percent of respondents mentioned that in some cases, men decide what foods to buy without input from women. This scenario is
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more likely in families with fewer financial means, because in those cases, men were more involved with food choices because they were concerned with buying lower-cost foods.
Usually, families eat three to four times a day, depending on the season. During the winter, families eat more often, up to six times a day. In the summer, families mainly ate three meals a day. Thirty-seven percent of respondents said that pregnant women eat four or five times a day, and also believed that pregnant women should eat a healthy diet rich in fresh vegetables, fruits, beans, soups with herbs, juices, etc.
Case Study 1: Sharifa Rahmatova, a woman from A. Jomi District “When I got married, I had to move from Vakhsh district to my husband’s house in A. Jomi district. That was during the post-conflict time (1991-1994 Tajikistan civil war) and many people were suffering from insufficient food in the region. I was young, and I didn’t know why my two sons were suffering from Rickets.
After a couple of years, our clinic nurse gathered all the women in our mahalla. She shared some information about maternal and child health and demonstrated some childcare practices. I learned about diseases that affect under age three and got information on rachitic and how to prevent it. My two children who had rachitic were already 12 and 15 years old, but I had another younger child, so, I started feeding my child every day by adding powdered eggshell to their food4. I also put the children down for a nap from nine o’clock in the morning to noon, but not in the cradle.
Now I’m 56 years old and more than 15 years has passed. Still, I feed my grandchildren and all my family members powdered eggshells, adding it to their tea or food. I taught my two daughters and my daughter-in-law to do this too.
This is a very important and positive behavior change to increase the nutrient content of regular meals. I think all women should be aware of this.”
In response to questions about meat consumption, fifty-one percent pointed that they eat meat very rarely due to the family’s financial situation —once a month, at family events, and/or at holidays like Eid Al Fitr and Eid Al Qurban. Nineteen percent of respondents said that they eat meat whenever have enough money to buy it (perhaps once a quarter), and another 18 percent of respondents said they eat meat once or twice a week. While most respondents mentioned that all family members eat meat, another roughly twelve percent of respondents mentioned that they try to serve meat to men and children under the age of five more often.
Regarding children’s egg consumption, almost seventy-three percent of respondents pointed out that children under-five should eat eggs. These respondents were well- informed of exclusive breastfeeding and specified that children should only start eating eggs after breastfeeding is completed at the age of two years and above. Most families can afford to buy eggs since they are reasonable priced. Twenty percent of respondents expressed a belief that a child under three or four years old should not eat eggs (especially egg yolks) because they were afraid it could lead to speech defects. According to seven percent of respondents, eggs are difficult for children to digest.
4 Author’s Note: this was a recommendation from a nurse who learned of this from a Mother Child Health training funded by Save the Children.
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In response to the question about why men and women do not pay attention to healthy food, over sevnty-six percent of respondents identified insufficient information about healthy foods as the primary reason. They pointed to family financial problems as another reason. Twenty-four percent of respondents told researchers that their personal families do not differentiate about healthy foods.
7.3 Men and Women’s Access to WASH
In terms of access to WASH, there is a gender gap in responsibilities and division of labor between men and women. Even though men are responsible for other laborious household tasks, all the work related to the water supply such as fetching water, general sanitation, and household hygiene generally falls to women and girls.
During the assessment, ninety-eight percent respondents said that water is accessible to them. Usually, families get drinking water from in-house faucets. Respondents from Jaihun said that eighty percent of the population gets water from water trucks and stores it in a special drainage basin made of cement. Men and boys are mainly responsible for the more arduous manual work, including carrying heavy containers filled with water across far distances. Women and girls are responsible for reserving, boiling, and preparing water for drinking, household use, and domestic chores. In Nosiri Khisrav district, water is available from the tap to households only for designated hours a day. Women in that district must store water by the bucketful several times a day. All family members have equal access to water.
As for toilets and latrines, eighty-three percent of respondents said that their toilet is located inside the house, and seventeen percent said that toilets are located outside. Many respondents indicated that outdoor toilets are safe for women and girls to use during the day and at night. Most respondents said that the toilets had electricity and are usually located not far from the house, but some respondents in A. Jomi and Qabodiyon said that girls only go to toilets at night if their mothers or grandmothers goes with them because the toilets are far away from their houses and girls are afraid to go alone at nighttime.
In response to the question of who usually cleans the toilet, ninety-three percent of respondents answered women or girls. They explained that men usually build the toilet.
On the question of access to soap, ninety-six percent of respondents said that all family members have access to and use soap.
When asked about handwashing practices, eighty-nine percent of respondents said that they regularly wash their hands with soap, especially after using the toilet, before eating, before cooking, and after returning home. They said that all families have washstands.
Eleven percent of respondents said that they wash their hands only after using the toilet but explained that they always use soap. They rarely wash their hands before cooking, before eating, or after returning home. The respondents were aware that washing hands
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is hygienic, but they explained that handwashing with soap before eating, before cooking, or after returning home is not practiced in rural areas.
Case Study 2: Qahramon Odilov a man from Pakhtakor village, Jaihun District Qahramon Odilov’s family lives in the most remote area of Pakhtakor village in Jaihun district. Every year, his family members suffer from diarrhea, and in 2018 one of them got typhoid. Almost every family in this region suffers from similar health problems. Qahramon wondered why this happened to his family and started conducting research. He discovered that the warehouse located in the nearby village of Ostrovsky is used to store pesticides and persistent organic pollution.
In the rural areas of Jaihun district, the residents use irrigated water for drinking. The irrigated water flows through the warehouse to the village of Pakhtakor, where many people live. Qahramon gathered his fellow residents of Pakhtakor, specifically local men and informed them about their contaminated water. He explained to the villagers that this contaminated water is the source of many infectious diseases in their village.
Next, Qahramon contacted a local organization and asked them to meet with the residents of Pakhtakor village and explain the effect of pesticides and persistent organic pollution on the human body. Thanks to Qahramon’s efforts, people in Pakhtakor village began to construct water tanks with a filter for their families and neighbors.
Women also began to boil water before using it for cooking and drinking. Now, all family members drink boiled water. Mothers also give children boiled water in bottles to take to school. All of these efforts have contributed to a rapid decline in the number of diarrhea and typhoid cases in this village.
In response to the question “who teaches children how to wash their hands”, ninety- three percent said that women and mothers are responsible. Seventeen percent of respondents said that children are taught at school how to wash their hands properly. Respondents indicated that men are not engaged in teaching children about washing hands. Men said the task of teaching children how to wash hands with soap as well as enforcing sanitation and hygiene practices at home mainly falls to women. In the context of COVID- 19, the respondents explained that washing hands has more recently become a habit and there is a notable shift in children’s behavior toward washing hands.
To the question “are women and men’s roles equal in regard to household hygiene and sanitation?”, nearly ninety-five percent of respondents stressed that women mainly take care of household sanitation and hygiene and only four percent mentioned that both men and women were involved in water sanitation and hygiene.
7.4 Women’s Economic Empowerment
The assessment findings suggest that even though women are actively engaged and involved in different economic activities both within and outside the household, there are gaps in women’s full economic empowerment, detailed below:
Eighty-one percent of respondents stressed that women actively participate and engaged in economic activities at the household and community levels.
On the question of who makes decisions concerning women’s economic activities, sixty- seven percent of respondents answered that men mainly make the decision. Twenty-three percent said that both men and women make these decisions together, and ten percent
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said that if the woman lives with her in-laws, the mothers-in-law and fathers-in-law also have a say.
Ninety-three percent of respondents said that women are not only responsible for household chores, but also involved in different farming activities including field work and cattle care. This is a result of the current economic situation in Tajikistan.5 Women have had to take on these additional responsibilities while continuing to cook, shop, clean, and look after children and other family members.
Respondents noted that women could combine both domestic and paid work—some women are nurses, teachers, jamoat workers, etc. In Jaihun and J. Balkhi districts, respondents pointed out that women are also engaged as general laborers (иҷора- наемные) for different types of work. Farmers or landowners hire local women and girls as day-laborers to harvest watermelons and carrots, clean a house after renovation, or other similar tasks. In many families, men and husbands have migrated elsewhere and women in these households are responsible for all household works.
In response to the question “who makes decisions about shopping?” seventy-one percent of respondents answered that women do the shopping. Men who responded said that women do better shopping, especially when buying food items like vegetables and other necessary ingredients for family meals. Nineteen percent of respondents said that both men and women do shopping, while ten percent of respondents from N. Khisrav district said that elders, especially mothers-in-law, make decisions about who should shop.
Eighty-seven percent of respondents pointed out that both men and women jointly decide meal plans. Thirteen percent said that mothers-in-law make the decisions about the menus for the family.
To the question “who makes a decision about when and who children should marry?”, seventy-three percent of respondents said that children made that decision for themselves, twenty-three percent of respondents said that parents decide for their children, and four percent said that elders decide.
Overall, forty-six percent of respondents said that women currently work in different sectors, including local government structures, colleges, clinics, schools, etc. Respondents from Jomi and Jaihun district pointed out that there are many women who work in state institutions, like local authorities, jamoats, schools, and health facilities, even in rural areas. This is in line with the Government of Tajikistan’s (GOT) efforts to promote the status of women in society.
5 Author’s note: The current economic situation in Tajikistan remains fragile, mainly due to corruption, uneven economic reforms and mismanagement. Since foreign income is dubiously dependent on remittances from migrant workers from abroad and exports of aluminum and cotton, the economy is highly vulnerable to external shocks. Majority men population are in migration and women are head of households, especially in rural areas.
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Forty-one percent of respondents in Levakant and N. Khisrav districts said that there are not many women with higher education in their area, and if there are educated women, their husbands do not usually allow them to work. Another five percent of respondents stressed that even if women have education, there are not many job opportunities that would be suited for their education.
To the question of “who controls women’s income?”, sixty-four percent of respondents said that women control their own income and thirty-six percent said that the husband and/or mothers-in-law control women’s income.
In response to the question about girls continuing their education after graduating secondary school, eighty percent of respondents from all four districts said that girls continue their education. The respondents stressed that educated girls are valued and education is very important for girls. Many families who arrange marriages for their children prefer to select educated girls for their sons. Young men are also interested in marrying educated girls as they believe that they make the best wife and mother. The respondents said that girls’ education has benefits for the future of women, their families, and the development and health of society. Respondents also shared that they knew girls from their region who are currently study abroad in including Russia, Germany, and China.
Case Study 3: Nafisa Davlatova, a woman from J. Balkhi District Nafisa Davlatova is from the village of Uzun in the Qarotegin area, and her community is very conservative and traditional. She was very shy, and rarely spoke up in public. Even among her family, she was very quiet. She tried to be a good wife to her husband and was considerate and kind to her in-laws, but she eventually became frustrated because she felt that her family did not value her contributions and efforts.
After she participated in events and seminars hosted by an ADB-funded activity about women’s empowerment, she began to feel more hopeful and tried to speak up more often. It was difficult at first because her husband would not allow her to speak her mind.
After some time, her husband left to work in Russia, and all the responsibilities for caring for her family fell on her shoulders. Her family members noticed that she was struggling and began to support her. With their help, she became more assertive at home and more active in community life. She even joined a local women’s group where she and other women work together to raise money each month. They use the funds to solve problems that affect their community, like garbage pollution which was affecting the community’s health due to the excessive heaps of waste and the pungent smell which was causing ill health. The main priority of these groups is to assist vulnerable families and individuals—especially pregnant women or single women with young children—to help meet their needs. This includes making sure that pregnant women attend their prenatal visits at medical centers and helping people purchase necessary medicines.
Nafisa attended the HMHB Gender Gap Assessment FGD with three other women from her village in her own motorized rickshaw. She has been a member of the women’s group for many years, and even today her neighbors seek her advice when they need assistance. She has become one of the most active women in her community and has improved the quality of life in her town. Her family is very supportive of her work.
Looking back, Nafisa is amazed at the progress she has made is happy to play such a significant role in her community. She barely recognizes the timid, shy girl she once was. She believes that if a woman has economic opportunities, it will benefit not only her family, but the entire community.
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Twenty percent of respondents mentioned that the reason that girls do not continue education is because their families are conservative, or because their parents have no education and create barriers for their daughters who want to continue their education. Such parents think that girls should get married rather than pursue their education. The respondents from Jaihun district mentioned that there are not many girls from their district that continue to study after they graduate from secondary school.
When respondents were asked “if they could change one thing about their life or their community, what would they like to change, and why?”, eighty-six percent of them indicated that they would promote women and girls’ status and strengthen their role in society so that women can be free and independent. The respondents were very hopefully and believed that they could achieve these objectives if all stakeholders build capacity and raise awareness of gender equality and women economic empowerment.
In response to what they could contribute to promoting women and girls’ status, fourteen percent of respondents said if there were more funds, they would build schools, clinics, stadiums, bathhouses, libraries, kindergartens, sewing factories, workshops for pasta (macaroni) production, and entertainment centers for children and youth. They said that by fundraising for and developing small projects they could support men and women to be economically empowered and independent in making their own decisions.
7.5 Gender Relationships and Power Dynamics
Even though women in target districts have education, work in local government, and manage the financial and social issues of the household, there is a gap between men and women in gender roles and relationship dynamics. Unfortunately, women are still not fully empowered and independent in decision-making and face discrimination and various forms of violence.
Researchers asked respondents certain questions related to gender aspects of health and nutrition. To the question of what social values, attitudes, and pressures within families affect women and children’s health, eighty-three percent of all respondents mentioned stereotypes, prejudice, socio-economic situation of the family, and domestic violence. All these factors influence the health status of women, children, and other family members.
In Jaihun district, the respondents explained there is an insufficient number of health workers. The only available nurse serves three villages, there is a lack of local clinics in villages (as the only clinic is in the center of the district), and the distance to the clinic is rather long for most people.
To the question “what is the best way to involve women in community development activities, especially in remote areas?”, ninety-three percent of all respondents mentioned capacity building training, seminars, awareness-raising campaigns, conversations within families, engaging role models (both women and men) who are respected in the community to talk about their achievements in the family and community, and providing small grants to women and men to enable them to start their small business. Seven
HMHB GENDER GAPS ASSESSMENT 2021 21 percent of respondents said that it is difficult to reach traditional or conservative families as they are not interested in encouraging their family members—especially women and girls—to study and grow their potential.
To the question “what is the best place to engage women for community development activities?”, fifty-eight percent of respondents mentioned health facilities. Usually, clinics are full of women who come for medical check-ups, so they are a natural place to discuss community development activities with women. Twenty-three percent of respondents said that individual houses would be a better setting, while nineteen percent of respondents said the best place is the mahalla committee6 or school buildings.
The respondents were asked how men could be engaged in supporting women’s reproductive health and child feeding, and eighty-two percent of respondents said the best way is to invite both young and old men to attend trainings, meetings, information sessions, and discussions. Respondents also pointed out that information and materials containing important health information could be disseminated in the street, at markets, and at village centers. The respondents from Jaihun district stressed that demonstration sessions on healthy food targeted to men, especially young men, would build their capacity, raise their awareness, and support child feeding and healthy nutrition. Eighteen percent of respondents said that if stakeholders involve men and build their capacity, they will be aware of the importance of women’s health and the importance of nutritious food for children.
Case Study 4: Hasanov Kamoliddin, a man from Khuroson district “My family lives in a very remote village about 36km away from the district center. Going to the market or the hospital at the district center is challenging for us and for other families in our village.
Most of our villagers do not have permanent jobs and both men and women work as day-laborers. If they cannot find jobs, they have very little money to buy food. Another reason that people frequently get into financial difficulties is because they don’t know how to prevent seasonal diseases that affect children and women, and they end up having to purchase costly medicines.
One man from our village and I were invited to participate in a hygiene, sanitation, and economic empowerment workshop. When my friend and I returned to our village, we decided to talk to our neighbors, especially men and women who have two, three, or more young children, and shared with them some of the handouts and IEC materials that we got at the event. We also shared what we learned about adhering to hygiene and sanitation best practices, and how these small changes can save money and improve our quality of our life.
We informed families about the benefits of boiling water and the importance of protecting our water sources from children who want to swim in them and animals who drink from them. We also told them how important it is to air out rooms and keep households free of dust. Instead of buying harsh pesticides and fertilizers from the market, we encouraged our community to use compost and other mineral fertilizers to grow crops. People now prefer to eat fruits and vegetables that are grown without pesticides, because they are healthy for both our diets and for the environment.”
6 Author’s note: Mahalla committee is a kind of smallish community committee consists from the ordinary people from particular street or let say one avenue, but village based.
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To the question of who is responsible for family planning, seventy-three percent of respondents said that men are primarily responsible. Twenty-six percent said that family planning is the responsibility of both men and women.
To the question “who decides how many children to have?” fifty percent of respondents believed that men decided. Twenty-six percent of respondents said that women should decision how many children to have. Eleven percent said that both women and men should decide together. Thirteen percent of respondents said that mothers-in-law make decisions on how many children to have. Respondents from N. Khisrav district also pointed out that some men want to have more children, but mothers-in-law don’t allow.
In response to the question “where do women and men get contraceptive medicines and items?”, sixty-seven percent of people identified clinics and medical facilities. Thirteen percent said pharmacies and twenty percent said that usually nurse/midwives provide these items to them directly.
7.6 Key Influencers, Sources of Information, and Media Preferences
This assessment also explored sources of information, media, and communication materials used in target areas as well as key influencers that community members listen to and respect.
To the question “what is the role of older men and women in serving as role models and providing advice to younger women and men”? ninety-three percent of respondents both from KIIs and FGDs said that role of elder men and women is very important. Everyone listens to them, especially young people, and elders very freely share their life experiences. Only seven percent responded that nowadays very few families listen to elder people and indicated that younger people more frequently act without seeking advice or permission from elders.
To the question “what role does a community member play in the village, and could they promote changes in caring for mother and child feeding?”, eighty-seven percent said that community members, women, and men all play a very important role in the village and they can definitely promote changes in caring for mother and child feeding and household nutrition. Since the community members are actively involved in capacity building events, seminars, and campaigns, including health-related activities, they work closely with different families. Active community members are aware that regular medical checkups for women who recently gave birth are very important for both the mother and the new baby. If they see that young woman who delivered recently are not visiting clinics, community members can discuss with family members and identify the problem that woman faces that is preventing her from going to the hospital. If the problem is caused by the mothers-in-law, which is common, community members can talk to them and encourage them to look after the health of the young woman and child. This approach works well and many families have been open to advice and encouragement from their community.
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Respondents pointed out that respected and influential members of the community engage in many events, like raising awareness by visiting houses, conducting meetings, etc. For instance, during child vaccination campaigns, community members went door-to-door and talked to families about the importance of timely vaccinations for young children. Thirteen percent of respondents said that the family itself also should be responsible for promoting changes in maternal and child health i.e. families should be more interested in getting information about maternal and child health—if they were aware, they will inform other relatives and neighboring families about what is good and what is bad for maternal and child health.
In response to the question "what role does a religious representative play in village? Do they influence men, women, boys, or girls, and could they promote changes in caring for maternal and child health?”, eighty-nine percent of respondents pointed out that religious representatives play a key role in village life, because they frequently interact with the community. Religious leaders interact with men very frequently on Fridays during Juma Namoz (the prayer given on holiest day of the week). This provides a perfect opportunity for religious leaders to devote one-hour to the topic of caring for mother and children’s health. The respondents emphasized that people listen to religious representatives and follow the advice given during their sermons. Religious representatives often support families who have disputes, including woman who suffer from domestic violence, or couples who want to divorce. Religious leaders try help families using guidance based on Islam. Since both men and boys attend Friday prayers, the mosques are an ideal location to share information and discuss community issues including promoting maternal and child health.
Eleven percent of respondents said that there are people in the community that do not listen to or do not trust religious leaders, because they believe that some religious representatives misinterpret Islam.
When asked whether they were educated about nutrition and whether they felt empowered to make changes to their household diets, eighty-four percent of respondents said that boys and girls are educated on such matters and can influence changes in their homes. Respondents pointed out that when school children receive important information at school or from their teachers, they share it with their family members. Boys and girls trust teachers and strictly follow their advice, especially about nutrition, health issues, and WASH. Some respondents said that if schoolchildren are aware of healthy food and have had access to it since childhood, it will positively impact their behavior and practices during their whole life. 7
7Author’s note: Here we mean schoolchildren as a key influencer, source of spreading the information, promoters/agent. If schoolchildren are aware of healthy food and nutrition, they can inform their family members. If these schoolchildren are aware of healthy nutrition starting from their childhood, it may positively influence/impact their future own life. If they have no access to healthy food and knowledge on health, it may negatively influence their own and future family life.
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Seven percent of respondents said that some families do not listen to their children and ignore or are indifferent to information that children share. Nine percent of respondents said that they did not know whether parents and elders listen to young boys and girls.
To the question “where do men and women receive mass media information?”, thirty- one percent of respondents said that they receive necessary information from the internet and social media. Twenty-one percent mentioned television programs, and eight percent identified local radio programs. Only three percent of respondents pointed to local newspapers and journals as the primary source of information. Thirty-seven percent of respondents said that the best source of information is information, education, communication (IEC) materials (booklets, brochures, and posters).
It was asked how materials could be improved or used more effectively, and ninety-two percent of respondents said that information and language should be simple to read for women, men, children, and the elderly, especially those living in rural areas. Respondents also noted that high quality materials, printed in color, combined with meaningful pictures and concrete infographics would be particularly useful. They also mentioned that large fonts conveying key information on health, child feeding, nutrition, WASH, and prevention of diseases would meet the needs of those living in rural areas.
Eight percent of respondents explained that they do not usually read booklets or brochures, and prefer to use the internet for information.
We also asked respondents how media, especially radio and television, can be used effectively to reach men and women. Respondents explained that television and radio programs should talk about important and useful information and take rural peoples’ needs into consideration. They also thought it would be useful to broadcast short, meaningful, and educational videos that promote healthy behavior changes for people in rural areas. For example, through demonstration of short video clips using TV and/or radio broadcast on proper handwashing, useful information on preparing healthy and nutritious food for mothers and children, or encouraging men to participate in this shows/or in video clips.
Seventy-four percent of respondents said that one of the best methods of conveying important information is through in-person theater performances, because they may leave a strong impression on people and influence their thinking.
Forty-nine percent of respondents felt that activity demonstrations—like scenarios and campaigns—provide critical information on gender, nutrition, and WASH to people in rural areas (for example, activity demonstration or campaigns with school children and community members engaging and playing different roles). The demonstrations and campaigns could demonstrate reality and it will be more accessible to perceive the content properly. Respondents felt that most Tajik men still do not believe that men and women are equal, but activity demonstrations can effectively sensitize people to gender equality.
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Researchers asked participants how activities and campaigns could be improved, and fifty- one percent of respondents stressed that it would be beneficial to invite men to activities, not only women and girls. Men can also benefit from demonstratation sessions on preparing healthy food, appropriate foods for children of different ages (0 to 3), nutritional value of various vegetables and fruits, and foods that contain vitamins and high calorie content. Respondents stressed that such campaigns should be organized in various villages and jamoats—not just the district center and the same audience.
7.7 Focus Group Discussions
Researchers held FGDs in four districts (J. Balkhi, Khuroson, Yovon, and A. Jomi), with 31 participants, including 18 men and 13 women. The questions for FGDs were different from KII questionnaires.
To the question "what are the most important changes in the roles of men, women, boys, and girls in your village or region that are underway now?”, over fifty-four percent of respondents said that there are important changes happening in the shifts of roles of women, men, boys, and girls. In comparison with the situation ten or so years ago, women are now promoted to high positions in local authorities, including deputies, farm leaders, and school principals. The respondents from Khuroson district mentioned that thirty-five percent of district-level council members are women, and in Yovon district the majority of district-level council members are women.
Seven years ago, only thirty-six percent of girls continued their education, and now sixty- seven percent of girls continue to study in universities and colleges after graduating from secondary school. There are girls and boys from Yovon and J. Balkhi districts who study outside of Tajikistan, in countries like Russia, China, Germany, and the United States. The respondents said that certain laws and state policies helped empower women, enabled them to pursue an education, and launched them on their path to success. Another factor that enabled this achievement could be the government quotas that give opportunities to girls from remote areas to continue their education.8
Researchers were aware that important changes were taking place in district infrastructure, like building modern hospitals, kindergartens, and sewing factories in Qabodiyon district, constructing bakeries and new medical centers in N. Khisrav district, constructing a large stadium in Khuroson district, and developing an initiative in J. Balkhi district to collect garbage (which is critical to preventing disease as the garbage from nearby villages caused many illnesses).
When asked who was responsible for these changes, forty-two percent of respondents said that government authorities, municipalities, and jamoats were the catalyst. Fifty-four percent said that changes happened because the community took initiative, either through
8 Author’s note: In the upper, 7 to 11, grades, the dropout rate of girl’s attendance increases especially in rural areas. Presidential quotas are given only for girls from rural areas, so that they have opportunity to continue their study after the secondary school. It’s encouraging girls’ participation in technical subjects and scholarships.
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mahalla committees or the advocacy of young people. When asked if anyone opposes these changes, sixty-one percent said that no one opposes them, although thirty-one percent felt that there were some people in their community opposed these changes.
Respondents were asked how these changes affect the number of children in the family and birth intervals, and ninety percent of respondents said these current changes and tendencies have positive implications for family planning. In earlier years, families preferred to have ten to twelve or at least six to seven children, but now both men and women, especially younger ones, prefer to have from three to four children. People understand that they should plan in advance for raising and educating children and think more broadly about children’s futures. The respondents noted that some mothers-in-law even understand and support the trend of smaller families. Ten percent of respondents felt that there are some negative aspects of having a smaller family and did not think this was a positive trend.
When asked about care for pregnant and lactating women, seventy-six percent of respondents said that families support pregnant and lactating women. Husbands understand how important it is for pregnant and lactating women to eat a high-calorie diet rich in vitamins and essential nutrients as it contributes to the health of both mother and a child.
To the question “how are fathers are involved in taking care of babies and feeding their children?”, thirty-eight percent of respondents said that men have an important role and there are families in their village where men are involved in caring for and feeding children. Respondents said that men took on this obligation when they decided to marry and have children. Sixty-two percent of respondents said that in some families, unfortunately, men do not contribute and instead think it is women’s responsibility to take care of babies and feed their children. The respondents also stressed that migration also plays a role; when men are absent from the family, women must take care of the children.
To the question “do you see any gaps in the current local administration and government policies on gender?”, sixty-nine percent of respondents answered that despite the fact that many women are employed at levels equal to men in the local administration structures, gaps remain. The respondents said that women work under pressure from management, and there are often misunderstandings and disputes in their families because women may come home late. There were even cases of divorce in some families, according to respondents from Yovon and Khuroson districts. Respondents mentioned that in some cases, women cannot take their annual leave due to their work obligations. Some women have even gone three or more years without taking their leave. Respondents also mentioned that women—especially young women—are harassed by male colleagues in the workplace.
In some cases, women took maternity leave and often did not return to work. In Tajikistan, if a working woman takes longer than two years of maternity leave, she will lose her job. Twenty-nine percent of respondents said that most men think that women should only look after the family, care for children, and they obey their husband.
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We also asked respondents about key gender issues that they address in their work and activities. Since many of FGDs members were local government officials, leaders of mahalla, and active community members, sixty-one percent of them said that they have close cooperation with families in the community and provide advice to men, women, boys, and girls. If there is a conflict within a family, including problems with children or early marriages for children, they involve other influential community representatives and all of them work together to support the family. If the case requires legal intervention, they guide people to legal support centers or directly to local lawyers.
7.8 Key Partner and Project Capacity to Deliver Gender Responsive Services Discussions with Activity staff, district coordinators, health promoters, and other stakeholders indicate that they have a basic understanding of gender concepts; yet many are not fully aware of value and benefits of mainstreaming gender in their daily work and project activities.
It is crucial to allocate financial resources and conduct capacity building trainings for partners, stakeholders, and health promoters about importance of gender equality and human rights and their implications for the HMHB Activity.
The HMHB Activity has assigned a gender focal point on staff. Gender mainstreaming, however, is not only the responsibility of a gender focal point; it is the responsibility of the entire team and others involved in project implementation.
The Activity staff (mostly district coordinators) have extensive experience implementing project activities. They participated in many capacity building trainings relevant to the project’s thematic areas. Next, it would be useful to build their capacity in gender mainstreaming with a focus on conducting gender-sensitive needs assessments, integrating gender into project implementation, carrying-out gender-responsive monitoring and evaluation, and enhancing women’s empowerment.
HMHB Activity staff and other partners are key in promoting gender equality and women’s empowerment outcomes through transformative training and respecting human rights.
8. CONCLUSIONS
Overall, respondents confirm that women and men have unequal access to the health care service and gender inequalities and gaps persist, especially regarding women’s decision- making power and roles.
Men (husbands, fathers, and fathers-in law) traditionally hold decision-making power when it comes to family and household issues, and mothers-in-law also play a key role. Most women are financially dependent on their husband. To visit a doctor or take a child to a health center, women often need permission from family elders or male relatives. When
HMHB GENDER GAPS ASSESSMENT 2021 28 women fall ill, become pregnant, or even deliver a baby, they cannot independently make the decision to go to the doctor. The few cases in which women independently go for medical care or take their children to doctor are exceptions to the norm. In some cases, women can make decisions upon mutual agreement with their husbands.
Domestic violence is another barrier hindering women’s rights and potential. Because domestic violence is so widespread, some women have unfortunately accepted it as normal and consequently do not seek support. Many women are clearly not aware of available services and GBV resources in their district. On a more promising note, some respondents said that families still face gender-based violence.
A Committee on Women and Family Affairs under the Government of the Republic of Tajikistan in each district is responsible for providing support to victims of violence. Women Resource Centers (funded by Organization for Security and Co-operation in Europe/OSCE) in Khuroson and Balkhi districts also provide legal and psychological support to vulnerable groups of women, including victims of domestic violence.
HMHB can play a pivotal role in reducing GBV in target areas and support women who are victims of violence. The Activity does not directly work on GBV, but it does work with rural women and their families on decision-making. HMHB also works directly with health promoters and local clinics. If Activity staff hear or witness GBV cases, DC and Health Promoters should refer women to local services or resources. Women are usually visiting local clinics for medical check-ups during pregnancy, after birth and for child health issues. Health staff should be trained by HMHB on gender and GBV and be able to recognize some signs (it may detect by the traces of beatings on the body, or any other health condition of the woman that is due to physical violence) and how to speak with the women and provide resources.
People with disabilities face unique challenges in rural areas, even though people without disabilities try to support and assist them with food, clothes, or mobility aids. Unfortunately, there is no comprehensive understanding of the total number of people with disabilities or their needs. It is important to consider the needs and perspectives of people with disabilities and ensure they have equal access to existing services as well as can fully participate and benefit from HMHB’s activities.
This assessment determined that the burden of ensuring good nutrition and WASH for the household usually falls on women’s shoulders. About half of respondents felt that “men do not pay attention to healthy foods and nutrition because they do not have sufficient information about healthy foods.” Many men said that there are very few capacity-building events for them to learn about health and diet, nutritious food, how to prepare healthy foods for young children, and other critical nutrition-related information. Most respondents agreed that existing awareness-raising materials and campaigns are mainly targeted to women, but felt that men and boys could also benefit from this information.
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The assessment findings also illuminate existing gender gaps in WASH; although men are responsible for initial construction and maintenance of household WASH infrastructure such as toilets, latrines, and various water storage solutions, women are responsible for the day-to-day household WASH activities. In some cases, men are also responsible for supplying water to tanks or water basins. For the most part, daily chores of boiling water, cleaning toilets, cleaning the house, and ensuring that children and other family members adhere to established hygiene practices fall to women. Ninety-four percent of respondents believed that daily household WASH activities are women’s responsibility, and only four percent believed that these duties should be shared equally between men and women.
As for women’s economic empowerment, some respondents reported that there is a high percentage of educated and working women, and that women’s position in society has improved. Full economic empowerment of women, however, is not yet realized and women and men’s roles in the community are still not equal. Though many respondents were familiar with basic gender equality concepts, many did not have advanced understanding of gender equality, gender equity, and gender norms.
Including gender-sensitive approaches in primary health care, WASH, and women’s economic empowerment are paramount to achieving public health outcomes in Tajikistan. Mainstreaming gender in HMHB offers opportunities to better integrate nutrition and health approaches. This will require increased collaboration and coordination between organizations working in the field of gender to apply a holistic approach. Mainstreaming gender in HMHB can only be accomplished if an accountability framework is in place and responsible staff at all levels are trained and committed to gender commitments. This means engaging every level of Activity staff, from senior management to district coordinators, to ensure everyone is held accountable for prioritizing gender and ensuring gender-responsive implementation. All parties must maintain open channels of communication and provide regular updates on how each activity contributes to overall health outcomes and gender equality. Other implementing partners and key stakeholders should also incorporate gender into their regular work, programs, and projects.
Facilitating gender-friendly community infrastructure is also critical, like making childcare services available at households and at community levels. Increased ownership and accountability of all household and family members is required to ensure balanced distribution of tasks between men and women. For example, HMHB should build capacity of targeted families and community members in the 12 districts in decision-making especially around family budgeting.
Gender-transformative health policies and practices throughout all health facilities and communities will improve gender parity and gender equality and will help to increase the number of women in leadership and decision-making roles in the health care sector.
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9. RECOMMENDATIONS
Based on these findings, HMHB should:
Apply strategic approaches to gender mainstreaming across all activities— including health, nutrition, and WASH—to boost gender equality and women’s empowerment beyond gender parity. Beyond including women in activities as participants or beneficiaries, there is a need to tailor interventions to enhance Activity effectiveness through inclusion and gender-sensitivity. Women may be targeted as key actors or as a vulnerable group in light of their historical and traditional position in the society, but we must also engage men to address their needs and empower them as equal partners in the struggle for gender equality.
Engage youth. Children and youth clearly benefit from nutrition and WASH messaging at an early age; they are particularly open and receptive to information, and they can carry these healthy habits forward into the next generation. Furthermore, they can reap immediate benefits, as eating a healthy and nutritious diet is vital for children’s cognitive, physical and emotional development. Reaching young people with messages about family planning and gender equality are also critically important because they will benefit from this information as they get married and have children. Sensitizing young people to gender equality and related concepts can help ensure a more just and equitable future for everyone. Youth can also influence their family, peers, and community by sharing important messages about gender, nutrition, and other key public health topics.
Promote fair distribution of household tasks between men and women in nutrition programs and activities. While childcare is traditionally considered a women’s responsibility in Tajikistan, nutrition interventions may encourage fathers to acknowledge their responsibility and play a more active role in childcare. This will, in turn, enable women to have more time to contribute to household income and nutrition. When childcare services are accompanied by sufficient supply of nutritious and diverse foods as well as nutrition education and behavior change activities, HMHB will be more likely to achieve nutrition outcomes.
Integrate gender considerations for each activity at the early stage of planning. Both female and male beneficiaries and stakeholders should be involved during the formulation, design, and implementation phases to better identify the most pressing needs, plan activities, develop communications strategies and messaging, and ultimately, advocate for and deliver the messages, services, and activities.
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KEY RECOMMENDATIONS BY THEME The below provides a road map of specific interventions around three themes: Advocacy and Collaboration; Transformative Capacity Building and; Communication and Knowledge Management.
Advocacy and Collaboration
• Collaborate and network with community leaders, district authorities, religious leaders, and schoolchildren to encourage and support them to play a key role in health service delivery (including nutrition, WASH, etc.) • Collaborate with relevant stakeholders—including influencers—to sensitize communities, families, and individuals regarding the importance of high-quality nutrition for women and children. • Work closely with the traditional leaders (mahalla committees, religious leaders, community activists, community leaders, and civil society activists) to challenge harmful traditional practices and beliefs that have negative implications on women and children’s health and nutritional statuses. • Intensify advocacy efforts aimed at men in support of gender equality and women’s empowerment, including in reproductive health decision making, nutrition, and WASH. • Strengthen synergy and linkages with other programs and organizations in the region working on gender issues and in the health sector. • Strengthen effective collaboration and cooperation between the health delivery system, social support networks, and other structures (like the District’s Department of Committee of Women and Family Affairs and women’s resource centers) in assisting victims of gender-based violence.
Transformative Capacity Building
• Build capacity of men and youth through trainings and seminars on reproductive health, nutrition, care of children, etc. • Build capacity of mothers, mothers-in-law, and husbands on gender equality in health, nutrition, WASH, GBV, and disability issues. • Engage men and boys separately and together with women and girls to discuss gender norms, roles, and relations to promote more equal relationships. • Engage men and boys in health and nutrition awareness-raising activities in targeted project villages and jamoats (not just in district centers). • Build capacity of health promoters on gender equality and human rights so that they deliver gender-responsive services in a more efficient and effective manner by integrating human rights and gender principles. • Build the capacity of healthcare providers to recognize and effectively manage all patients including victims of gender-based violence (and ensure they are equipped to refer GBV victims to appropriate resources).
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• Conduct community mobilization sessions on gender, health, and nutrition; prevent and eradicate harmful traditional practices using community-based groups. • Empower women through behavior change communication campaigns to promote their decision-making power regarding health and nutrition at both family and community levels. • Build the capacity of gender focal points and district coordinators to effectively facilitate gender mainstreaming in implementation, monitoring, and evaluation of project activities.
Communication and Knowledge Management
• Develop visual IEC materials with concise and specific information using accessible local languages (i.e., Tajik and Uzbek) for different groups, including men, women, boys, and girls. • Distribute posters, infographics, and visual materials that showcase positive images of women who have contributed to health, nutrition, and gender, and who have leadership and influential roles in the community. • Develop community mobilization and media campaigns using informal community- based groups and engage women, men, boys, and girls in advocating for gender equality, nutritious food, and WASH outcomes. Consider involving local mobile theaters and working with schoolchildren to conduct peer-to-peer initiatives. • Develop IEC materials that will challenge negative perceptions and uncompromising attitudes of men and women towards health services by suggesting positive alternatives and options. • Conduct information sessions on demonstrating preparation of healthy and nutritious food. Involve men and youth so that they can understand the importance and necessity of nutritious food for all family members, especially for children and pregnant and lactating women. • Submit a gender equality and women’s empowerment section in the annual report to report progress, lessons learned, and challenges of gender mainstreaming during the lifespan of project.
10. ANNEXES
10.1 Annex I: Case Studies
After the completion of the KII and FGDs, some of the respondents from four districts were asked to share their experience on access to WASH, health care, nutrition, economic opportunities, resources and information as well as their gender experience and challenges they face in their life.
The four case studies, incorporated in the body of the report, illustrate the experience of two men and two women on the challenges, access and changes happened in their life. Names have been changed to protect the respondent.
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10.2 Annex II: Data Collection Questionnaire
Key Informant Interviews/KIIs (Community members—women and men— implementing partners, local community leaders, and district officials)
Health sector
1. Are both women and men seeking health care when they are sick? Yes/No If no, why? Do they (specify men or women or both) face challenges in obtaining health services? Specify the reasons (e.g., the road to the district hospital is not repaired, insecure, difficult for men and especially pregnant women)
2. Do you think all sick women attend health facilities? Yes/No If no, why?
3. Who is consulting traditional healers or seeking alternative therapies more? Women? Men? Certain age groups? Certain socioeconomic groups? Why these groups?
4. When a woman is pregnant, does she visit a local hospital/a doctor? Yes/No If yes, how many times? If no, why? (the clinic is far from the house, due to household chores, she cannot go to the doctor during the day, she does not have enough money to pay the doctor’s fee, etc.)
5. Are children regularly taken to health services? Yes/No If yes, how often? If no, why?
6. Who is responsible to take children to health services? If it is a woman, can she go without her husband’s permission? Yes/No If no, why?
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7. Do husbands pay for doctor’s fees/treatment? Yes/No If yes, why? If no, why?
8. Do husbands join their wives during the clinic visits? Midwives? Yes/No If no, why?
9. Where do women deliver their babies? If at home, why? Who helps?
10. Is it (or not) important for men to know about pregnancy and childbirth? Yes/No If yes, why? If no, why?
11. Would men like to know more about overall health, pregnancy, and childbirth? Yes/No If yes, why? If no, why?
12. Would men like to stay beside their wives during the delivery of their child? Yes/No If yes, why? If no, why? 13. Are there any people in your community with physical, mental, or emotional disabilities? Yes/No How are they cared for? Are they part of the community or are they considered outsiders? What should be done to support people with disabilities in your community?
Nutrition Sector
1. Who usually buys food products in the market? (Men? Women? Other?) 2. Who controls the menu in the family? (Men? Women? Other?) 3. Who cooks more than anyone else in the family? (Makes bread? Makes tea?) 4. How many times do family members eat at home?
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1 2 3 4 5 5. How many times do breastfeed women and pregnant women eat at home? 1 2 3 4 5 6. How often do you eat meat at home? 1 2 3 4 5
7. When you have meat how much do men eat? (Women? Boys? Girls?) 8. Do children under 5 eat eggs? At what age do they start eating eggs? If they do not eat eggs, why (price, availability, access)?
9. Would you like to learn about what foods a mother and baby should eat at different times so children would be stronger and more intelligent? Yes/No If yes, why? If no, why?
10. What foods and medicines should a woman eat and avoid before she gets pregnant and when she is pregnant? Why? 11. What foods and medicines breastfeeding woman should eat? Why? 12. What food and medicines a breastfeeding woman should not eat? Why?
WASH Sector
1. Where does your family get drinking water from? (River, pump, standpipe, water-truck, in-house faucet) 2. What is the role of men and boys in collecting and storing drinking water? 3. What is the role of women and girls in collecting and storing drinking water? 4. Do men and women, boys and girls can equally drink clean water in the family? Yes/No If no, why?
5. Is your toilet outside or inside the house? 6. If it is outside, can women and girls go at any time during the day and night? Yes/No If no, why?
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7. Who usually cleans the toilet? (Men? Women? Boys? Girls?) 8. Are there hygiene products available for adolescents? 9. Where do you wash your hands? (washstands, ditch, canal) 10. Who educates children about how to wash hands? (Men? Women? School?) 11. At what times do men, women, boys, and girls wash their hands? (after using the toilet, before eating, etc.) 12. How are women and men involved in the hygiene and sanitation of the household?
Economic Empowerment Issues
1. How do women engage in the economic life of households in your village/region? 2. Who decides what economic activity should women be engaged in? (Men? Women? Other?) 3. Are women responsible only for household chores? Yes/No If yes, why? If no, why? 4. Who makes decisions about shopping? (Men? Women? Grandfather? Grandmother?) 5. Who makes the decision about food to eat? (Men? Women? Grandfather? Grandmother?) 6. Who makes decision about children going to school? (Men? Women, Grandfather? Grandmother?) 7. Who makes a decision about visiting the clinic for women and kids? (Men? Women? Grandfather? Grandmother?) 8. Who makes a decision about when and who children should marry? (Father Mother? Grandfather? Grandmother?) 9. Do women go to work? Yes/No 10. Who controls women’s income? 11. Do girls continue their education after graduating from school? Yes/No If yes, why?
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If no, why? 12. If you could change something about your life/life in this village/community what would you like to change, and why?
Gender Dimension:
1. What social values, attitudes, and pressures within families affect women’s and children’s health? 2. What is the best way to reach women for community development activities (especially in remote areas)? 3. What is the best place (own home, village, PHC etc.) to engage women in community development activities? 4. Why in some families do men not pay attention to healthy food? What about women? 5. How can we involve men to support the reproductive health of women and child feeding in your community? 6. Who is responsible for family planning? (Men? Women? Mother-in-law?) 7. Who decides how many children to have? (Men? Women? Mother-in-law?) 8. Where do women and men get contraceptive medicines and items? 9. What should be the role of elder men and women in reaching younger women and men? 10. What role does a community member play in the village? 11. Could he/she promote changes in caring for mothers and child feeding? (If yes, in what ways?) 12. What role does a religious representative play in village life? 13. Do they influence men or women, boys, or girls? 14. Could he/she promote changes in caring for mothers and child feeding? (If yes, in what ways?) 15. If boys and girls were educated about nutrition, would this lead to changes in their homes? 16. Where do men and women receive mass media information? (clinic, television, radio, materials (brochures, booklets), social media or any other sources of communication?) 17. How could information materials be improved or used more effectively?
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18. How can media (especially radio and television) be used effectively to reach men and women? 19. 19. How important are demonstration activities (scenarios, campaigns, etc.) for the promotion of gender equality? How could they be improved? 20. Please explain what domestic-based (or gender-based) violence is. In your family, are there conflicts with the use of physical force towards any family members? 21. Is it okay for a woman to be hit by her husband? If yes, why? If no, why? 22. How are these conflicts perceived by the household, community or by the woman herself?
Focus Group Discussions/FGDs among implementing partners, local government structure, leaders of mahalla, active community members
1. What are the most important changes in the roles of men, women, boys, and girls in your village/region that are underway now? Who is making these changes? (e.g.: urban only?) Who (if anyone) is opposing them and why? (e.g.: men only?)
2. How are these changes affecting? The number of children that people of your age want and how they would be spaced? How pregnant and lactating women are cared for? How fathers are involved in taking care of babies and infants? How fathers are involved in feeding their children?
3. Do you see any gaps in the current government policies or local government structures on gender (in your area)? 4. What are the key gender issues that you solve in your work/activities? How do you solve them?
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10.3 Annex III: Tables
Table 1. Number of FGDs
Districts Number of Female Number of Male Total Participants Participants Occupation Khuroson 4 4 8 1 man-Healthy Lifestyle Centre (HLSC) 1 man-Local authority (Head of Department of Work with Youth and Sport) 1 man-Representative from community religious groups 2 women-Active community members 1 woman-Teacher 1 woman-Activist from local authority, works in District Department of Statistics J. Balkhi 6 4 10 4 people-From local clinic (3 men and 2 women health promoters) 1 man-HLSC 1 woman-Teacher 4 women-Active community members (from different jamoats) Yovon 4 3 7 2 women-Department of Work with Women and Family Affairs (1 is a head of the department, 1 is the assistant to the head of department) 1 woman-Active community members 1 woman-Leader of mahalla 1 man-Active community member 1 man-Representative from Head of the Department of Religion, Regulation of Local Traditions and Ceremonies of the District’s Executive Body 1 man-Head of Department of Work with Youth and Sport Qabodiyon 3 3 6 1 woman-Head of Department of Work with Women and Family (district committee of women and family affairs) 1 woman-Assistant of the Department of Work with Women and Families
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Districts Number of Female Number of Male Total Participants Participants Occupation 1 woman-Active jamoat member 1 man-Leader of mahalla committee 1 man-Head of Department of Work with Youth and Sport 1 man- Representative from Head of the Department of Religion, Regulation of Local Traditions and Ceremonies of the District’s Executive Body Total 17 14 31
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Table 2. Number of KII Participants
District Number of Female Number of Male Total Occupation Participants Participants Jomi 0 2 2 1 man- Deputy to the Social Development and Public Relations Department 1man-Head of Department of Work with Youth and Sport Levakant 2 6 8 1 man- Representative from Head of the Department of Religion, Regulation of Local Traditions and Ceremonies of the District’s Executive Body 1 man-Specialist on jamoat development 1 man-HLSC 1 man-PHC 2 men-Community leaders 1 woman-Active mahalla leader 1 woman-Active community member Nosiri Khisrav 5 1 6 1 woman-HLSC 1 woman-Health promoter 1 man-Head of mahalla, 1 woman-Head of mahalla 2 women-Active community members Jaihun 2 3 5 1 man-Head of jamoat of Qumsangir 1 man-Leader of mahalla committee 1 man-HLSC 2 women-Active community members Total 9 12 21
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10.4 Annex IV: List of Literature
USAID Advancing Nutrition Gender Equality Strategy, 2019 https://www.advancingnutrition.org/resources/usaid-advancing-nutrition-gender-equality- strategy
Program Gender Equality Strategy, Nutritional International, Nourish life, 2018 https://www.nutritionintl.org/wp-content/uploads/2018/12/program-gender-equality- strategy-full.pdf
Gender Equality And Women’s Empowerment 2020 Policy, USAID https://www.usaid.gov/sites/default/files/documents/USAID_GenderEquality_Policy_MT_ WEB_single_508.pdf
Agriculture for Nutrition and Health Gender Strategy for Phase II Draft, Version 2.0 Updated March 2016 https://a4nh.cgiar.org/files/2014/03/A4NH-Gender-Strategy-Updated-August-2015.pdf
Engaging Family Members in Maternal, Infant And Young Child Nutrition Activities in Low- and Middle-Income Countries: A Systematic Scoping Review https://onlinelibrary.wiley.com/doi/10.1111/mcn.13158
Somaliland Gender Gap Assessment, OXFAM 2019 www.healthpolicyproject.com/pubs/121_ToolsforAssessingGenderinHealthPolicFINAL.p df
Gender Assessment, Mali, USAID July 2012 https://www.usaid.gov/documents/1862/usaidguatemala-gender-analysis-final- report-september-2018
CAREC Gender Strategy 2030: Inclusion, Empowerment, and Resilience for All Institutional Document | January 2021 https://www.adb.org/documents/carec-gender-strategy-2030
Gender Equality and Women's Empowerment Operational Plan, 2013-2020 https://www.adb.org/documents/gender-equality-and-womens-empowerment- operational-plan-2013-2020
Guidelines for Gender Mainstreaming Categories of ADB Projects, Institutional Document | March 2021 https://www.adb.org/documents/guidelines-gender-mainstreaming-categories-adb- projects
GEF Gender Implementation Strategy, GEF/C.54/06 June 1, 2018 www.thegef.org/sites/default/files/council-meeting documents/EN_GEF.C.54.06_Gender_Strategy_0.pdf
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Gender Equality and Women’s Rights, Council of Europe, Standards https://rm.coe.int/key-coe-standards/16809f22fb
Tajikistan: Country Gender Assessment, Institutional Document | June 2016 https://www.adb.org/documents/tajikistan-country-gender-assessment-2016
World Bank Group Gender Strategy (FY16-23): Gender Equality, Poverty Reduction and Inclusive Growth https://openknowledge.worldbank.org/handle/10986/23425
Behaviors to Improve Nutrition-infographic -USAID https://www.advancingnutrition.org/resources/behaviors-improve-nutrition
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