title: Balancing expectations amidst limitations: the dynamics of food decision-making in rural Kerala.
abstract: BACKGROUND
  Food decision-making is a complex process and varies according to the setting, based on cultural and contextual factors. The study aimed to understand the process of food decision-making in households in rural Kerala, India, to inform the design of a dietary behaviour change intervention.
  
  
  METHODS
  Three focus group discussions (FGDs) and 17 individual interviews were conducted from September 2010 to January 2011 among 13 men and 40 women, between 23 and 75 years of age. An interview guide facilitated the process to understand: 1) food choices and decision-making in households, with particular reference to access; and 2) beliefs about foods, particularly fruits, vegetables, salt, sugar and oil. The interviews and FGDs were transcribed verbatim and analysed using qualitative content analysis.
  
  
  RESULTS
  The analysis revealed one main theme: 'Balancing expectations amidst limitations' with two sub-themes: 'Counting and meeting the costs'; and 'Finding the balance'. Food decisions were made at the household level, with money, time and effort costs weighed against the benefits, estimated in terms of household needs, satisfaction and expectations. The most crucial decisional point was affordability in terms of money costs, followed by food preferences of husband and children. Health and the risk of acquiring chronic diseases was not a major consideration in the decision-making process. Foods perceived as essential for children were purchased irrespective of cost, reportedly owing to the influence of food advertisements. The role of the woman as the homemaker has gendered implications, as the women disproportionately bore the burden of balancing the needs and expectations of all the household members within the available means.
  
  
  CONCLUSIONS
  The food decision-making process occurred at household level, and within the household, by the preferences of spouse and children, and cost considerations. The socio-economic status of households was identified as limiting their ability to manoeuvre this fine balance. The study has important policy implications in terms of the need to raise public awareness of the strong link between diet and chronic non-communicable diseases.
authors.affiliation: Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, 695011, India. meena.daivadanam@ikv.uu.se.|Department of Food, Nutrition and Dietetics, Uppsala University, Box 560, SE-751 22, Uppsala, Sweden. meena.daivadanam@ikv.uu.se.|Department of Public Health Sciences (Global Health), Tomtebodavägen 18A, Karolinska Institutet, 171 77, Stockholm, Sweden. meena.daivadanam@ikv.uu.se.
authors.forename: Meena
authors.initials: M
authors.lastname: Daivadanam
authors.affiliation: Department of Public Health Sciences (Global Health), Tomtebodavägen 18A, Karolinska Institutet, 171 77, Stockholm, Sweden. rolf.wahlstrom@ki.se.|Family Medicine and Preventive Medicine, Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden. rolf.wahlstrom@ki.se.
authors.forename: Rolf
authors.initials: R
authors.lastname: Wahlström
authors.affiliation: Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, 695011, India. kavumpurathu@yahoo.com.
authors.forename: K R
authors.initials: KR
authors.lastname: Thankappan
authors.affiliation: Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, 695011, India. ravindrans@usa.net.
authors.forename: T K Sundari
authors.initials: TK
authors.lastname: Ravindran
mesh_terms: D000328:Adult; D000368:Aged; D003657:Decision Making; D004032:Diet / Q000191:economics* / Q000379:methods*; D005260:Female; D017144:Focus Groups; D005518:Food Preferences / Q000523:psychology*; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D012424:Rural Population / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D055815:Young Adult