The interplay between the market food environment and barriers to healthy diets for women in rural Bihar, India.

Understanding the barriers that women in rural, low-income settings face in acquiring nutrient-dense foods (NDFs) is fundamental to improving health. Most existing evidence comes from quantitative studies. However, complementary qualitative insights can deepen understanding of individuals' lived realities and inform contextually relevant strategies to address these barriers. We qualitatively examined how gender norms and other socioeconomic inequalities shape women's interactions with their market food environment for acquiring NDFs in rural Bihar, India's poorest and most undernourished state. We also considered men's experiences to understand gender differences in barriers. We sampled 12 villages across two districts (Bhojpur and Samastipur) and conducted 12 focus groups with women and 76 interviews with women and their spouses. A complementary survey was also conducted to contextualise our qualitative findings. The unaffordability of NDFs, caused by low income and high prices, was the main barrier to acquisition. This barrier was most pronounced for the poorest and was greatest during seasonal price spikes. Women faced unique affordability challenges due to their exclusion from markets, driven by restrictive gender norms that stigmatise their participation and view markets as unsafe spaces. Consequently, women relied on expensive local sources or travelled longer distances to more distant markets, diminishing food budgets. Affordability barriers for the poorest and lower-caste women were compounded by pay discrimination and gender norms that restricted women's livelihood opportunities. Our insights suggest that providing women with cash transfers, alongside the development of safer, more inclusive markets, could improve women's acquisition of NDFs and their nutritional health.