Forestry, Faculty of
Non UBC
Forest and Conservation Sciences, Department of
DSpace
BMC Public Health. 2021 Feb 15;21(1):355
The Author(s)
Gibson, Emily
Stacey, Natasha
Sunderland, Terry C. H.
Adhuri, Dedi S.
Background: There is growing recognition of the need for fish to be better integrated into nutrition-sensitive strategies for addressing malnutrition. Fish are overwhelmingly produced by the small-scale sector, which supports food and nutrition security directly through the provision of fish and indirectly through the generation of income which can be used to purchase other desired foods. However, there has been relatively little research on the extent of food and nutrition security in specialised fishing communities. This study assessed food and nutrition security among households in specialised fishing communities in Komodo District, eastern Indonesia. Methods: We assessed the seasonal nutrition quality of household diets using the Food Consumption Score for nutritional analysis and food insecurity using the Household Food Insecurity Access Scale in 66 households across three communities, using a modified cluster sampling strategy. We calculated and generated descriptive statistics for these indicators with Microsoft Excel and ran a logistic generalized linear mixed model to determine factors associated with severe food insecurity using SPSS. We used semi-structured interviews and focus group discussions to understand perceptions of, change over time, and strategies for dealing with food shortfalls. Results: While most households have acceptable access to nutritious foods, especially protein and heme iron-rich foods, nearly one half of households consumed vitamin A rich foods on less than 3 days of the 7-day recall period in either season. More than half of households reported experiencing a moderate or severe level of food insecurity, with higher food insecurity in the wet season. Low maternal education (OR: 3.8, 95%CI 1.5–9.9) and lower household wealth (OR: 0.5, 95%CI 0.3–0.9) were found to be associated with a severe level of food insecurity. Household’s consumptive and non-consumptive response strategies reflect adaptation to chronic food insecurity but are nutritionally and economically unsustainable. Conclusion: Households in specialised fishing communities in Komodo District consumed diets with low diversity and experienced high levels of food insecurity. There is a need for culturally-appropriate nutrition-sensitive strategies to enhance food and nutrition security in vulnerable fishing communities.
RESEARCH ARTICLE Open AccessCoping or adapting? Experiences of foodand nutrition insecurity in specialisedfishing households in Komodo District,eastern IndonesiaEmily Gibson1* , Natasha Stacey1, Terry C. H. Sunderland2,3 and Dedi S. Adhuri4AbstractBackground: There is growing recognition of the need for fish to be better integrated into nutrition-sensitivestrategies for addressing malnutrition. Fish are overwhelmingly produced by the small-scale sector, which supportsfood and nutrition security directly through the provision of fish and indirectly through the generation of incomewhich can be used to purchase other desired foods. However, there has been relatively little research on the extentof food and nutrition security in specialised fishing communities. This study assessed food and nutrition securityamong households in specialised fishing communities in Komodo District, eastern Indonesia.Methods: We assessed the seasonal nutrition quality of household diets using the Food Consumption Score fornutritional analysis and food insecurity using the Household Food Insecurity Access Scale in 66 households acrossthree communities, using a modified cluster sampling strategy. We calculated and generated descriptive statisticsfor these indicators with Microsoft Excel and ran a logistic generalized linear mixed model to determine factorsassociated with severe food insecurity using SPSS. We used semi-structured interviews and focus group discussionsto understand perceptions of, change over time, and strategies for dealing with food shortfalls.Results: While most households have acceptable access to nutritious foods, especially protein and heme iron-richfoods, nearly one half of households consumed vitamin A rich foods on less than 3 days of the 7-day recall periodin either season. More than half of households reported experiencing a moderate or severe level of food insecurity,with higher food insecurity in the wet season. Low maternal education (OR: 3.8, 95%CI 1.5–9.9) and lowerhousehold wealth (OR: 0.5, 95%CI 0.3–0.9) were found to be associated with a severe level of food insecurity.Household’s consumptive and non-consumptive response strategies reflect adaptation to chronic food insecuritybut are nutritionally and economically unsustainable.Conclusion: Households in specialised fishing communities in Komodo District consumed diets with low diversityand experienced high levels of food insecurity. There is a need for culturally-appropriate nutrition-sensitivestrategies to enhance food and nutrition security in vulnerable fishing communities.Keywords: Specialised fishers, Small-scale fisheries, Food and nutrition security, Dietary diversity, Indonesia© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.* Correspondence: emily.gibson@cdu.edu.au1Research Institute for the Environment and Livelihoods, Charles DarwinUniversity, Ellengowan Drive, Darwin, Northern Territory, AustraliaFull list of author information is available at the end of the articleGibson et al. BMC Public Health (2021) 21:355 https://doi.org/10.1186/s12889-021-10248-3BackgroundFood insecurity is a pressing global issue and contributesto malnutrition in all its forms (undernutrition, micro-nutrient deficiency, and overweight and obesity) throughthe complex interplay of food and non-food factors thataffect a person’s nutritional status [39]. In 2018 anestimated 820 million people were classified as under-nourished and two billion people were affected bymicronutrient deficiency or ‘hidden hunger’ [40]. “Hid-den hunger occurs when the quality of food people eatdoes not meet their nutrient requirements, so the food isdeficient in micronutrients such as the vitamins andminerals that they need for their growth and develop-ment” [100]. Hidden hunger can occur in those consum-ing too little food or in those consuming too muchenergy-dense nutrient poor food. Globally, undernutri-tion was the underlying factor in 45% of all deaths ofchildren under 5 years of age in 2011 [7], and subopti-mal diets are responsible for more adult deaths than anyother risks [44]. The most common nutritional deficien-cies are of iron, zinc and vitamin A, and multiple micro-nutrient deficiencies can occur together in the samepopulation [78]. The WHO [101] recommends con-sumption of a healthy diet to avoid nutritional deficien-cies and non-communicable diseases. A healthy dietcomprises an appropriate energy intake, increased intakeof fruits, vegetables, legumes, nuts and wholegrains,moderate intake of animal-source foods such as fish, andreduced intake of ultra-processed foods, to meet the nu-trient requirements of all age groups, including thosewith special nutrition needs, and is adapted to the localcontext and culture [77, 101, 104]. Ultra-processed foods“are typically high-energy-dense products, high in sugar,unhealthy fats and salt, and low in dietary fiber, protein,vitamins and minerals” ([76], p.1). They are generallymanufactured in an industrial setting, and in developingcountries are widely available as single-serve packagedsweet or savory snack foods. In the context of the mul-tiple burden of malnutrition, and the complex challengesof a growing global population and climate change, thereis growing recognition that healthy diets must also beproduced by sustainable food systems so as to ensurefood and nutrition security for present and future gener-ations [36, 52, 54, 104].Fish, and other edible marine resources (e.g. bêche-de-mer, octopus, sea shells, shrimp; hereafter “fish”), havelargely been overlooked in discussions of food-basedstrategies to address malnutrition in the context of sus-tainable food systems [10, 53, 62, 63, 68, 91]. Fish are anutrient-dense animal-source food which provides 3.2billion people with almost 20% of their average percapita intake of animal protein, with consumption higherin Indigenous fishing communities and small-island de-veloping States [17, 22, 38]. However, the nutritionalvalue of fish extends beyond protein, encompassinglong-chain polyunsaturated fatty acids, micronutrientssuch as vitamins A, B12 and D, and minerals includingcalcium, phosphorous, iodine, zinc, bioavailable hemeiron, and selenium [5, 11, 85]. Fish are an invaluableaddition to plant-based diets because they enhance thebioavailability of non-heme iron and zinc from otherfoods consumed in the same meal [69, 70]. In developingcountries, the small-scale fisheries sector, operatingacross marine, inland and aquaculture systems, employsan estimated 33.1 million fishers on a full- or part-timebasis, with an additional 2–3 people for every fisheremployed in postharvest activities; half of these workersare women [72]. The sector provides a safety net func-tion, with countless others engaged in fishing activity onan occasional and seasonal basis [6]. These activitiescontribute directly to food and nutrition securitythrough the provision of fish for home consumption andindirectly through the generation of income which canbe used to purchase other foods, including staples andlower-value fish, and to pay for other goods and services.‘Fish as food’ is an important lens for thinking aboutthe sustainability of fisheries and fishing communities [5,63]. Studies at a global scale indicate that in some coun-tries with a high malnutrition burden redirecting a smallportion of marine finfish landings to local rather thanexport markets could have a meaningful impact on thenutritional value of local diets, especially for childrenunder the age of five [51]. Studies at a local scale tend tofocus on the apparent availability of fish, particularly inthe context of marine governance and sustainability in-novations, rather than on how fishing contributes tofood and nutrition security within local fishing commu-nities. Kawarazuka and Bene [58] mapped evidence ofthese contributions across three pathways (income, con-sumption and distribution), but noted that more re-search was required to quantify the linkages betweenfish-related livelihoods and nutrition. Moreover, fishinghouseholds face heightened risk of food insecurity asthey are at risk of direct and trading entitlement failuresbecause their food and nutrition security depends on theconsumption of the food they produce (i.e. fish) and itssale to obtain other foods [14]. These risks may behigher in specialised fishing households and communi-ties that are constrained by limitations of access to pro-ductive resources, infrastructure, economic andinstitutional capacity, and where the socio-cultural tiesto fishing as a way of life are strong [20, 34, 60].In this paper, we present and analyze empirical datafrom a mixed methods exploratory case study of foodand nutrition security in three specialised fishing com-munities in eastern Indonesia. We use food consump-tion frequency data to assess nutritional quality of dietsat the household level, assess the prevalence and severityGibson et al. BMC Public Health (2021) 21:355 Page 2 of 17of food insecurity (access), and identify strategies usedby households to manage during times of food insuffi-ciency. The study contributes to the literature by identi-fying the vulnerability of specialised fishing householdsto chronic food insecurity and the need for cross-sectoral nutrition-sensitive programmes to improve foodsecurity in similar communities in the tropical coastalseascape.MethodsStudy areaIndonesia has the largest reef-associated population inthe world, with nearly one third of its’ 270 million-strong population living within 10 km of the coast [15,105]. The country is the world’s second largest producerof marine fish [38], with most of this catch harvested bysmall-scale fishers. Government data indicates that themajority of targeted commercial fish stocks are fullyexploited or overexploited [74], and fisheries productionis threatened by destructive and unsustainable fishingpractices, land-based pollution, as well as climate vari-ability [4, 15, 18]. Indonesia has demonstrated a high-level political commitment to improving undernutrition,yet it is ranked 73rd out of 119 countries in the GlobalHunger Index [95], the national prevalence of stuntingin children under 5 years of age is 36.4, and 28.8% ofwomen of reproductive age are anaemic [102].This research was undertaken in Komodo District,West Manggarai Regency, in the Province of Nusa Teng-gara Timur (NTT). Fisheries are an important contribu-tor to the local economy. Fishing and trading activity aredominated by Indigenous Sama-Bajau and Bugis house-holds who live in settlements near the main fish landingsite at Labuan Bajo and on numerous nearby islands.Fishing communities have slightly different fishing pro-files, targeting different species using different gear, witha network of patrons and middlemen providing connec-tions to local, domestic and even high-value export mar-kets. While it is typically men who go to sea, women areinvolved in activities across the local value chain. How-ever, women’s involvement is predominantly in unpaidpre- and post-harvest activities that support their fisherspouse and extended family, or in seasonal post-harvestwork for which they are remunerated with fish. The gen-dered division of labor reflects both Indigenous cultureand Islamic religious observance.In 2017, 20% of the District’s population were classedas poor [13]. A food security and vulnerability assess-ment conducted in 2015 by the Provincial government,in conjunction with the World Food Programme, con-sidered Komodo District ‘food secure’ [46]; however onlyone third of households had access to electricity, 46%had access to clean water and 49.31% of children underfive had stunted growth [46]. A recent local study relyingon food balance sheet data found that diets were lackingdiversity [82].Our case study sought to provide a holistic assessmentof food and nutrition security in specialised fishing com-munities. Our research was guided by a comprehensivereview of the literature and Kawarazuka and Bene's [58]pathways framework, which is in itself based on theUNICEF [93] ‘determinants of nutritional status’ (seeTable S1). The three pathways (income, consumptionand distribution) in which fish may contribute to foodand nutrition security are mapped across the basic,underlying and immediate causes of nutritional status(or outcomes). We purposively selected three villages forour case study, each situated on a different islandlocated between seven and 14 km from Labuan Bajo.There was a high prevalence of fishing livelihoods ineach of the villages, but the villages differed based ontheir structure (formal / informal village status), geog-raphy (small rock outcrop to large savannah island,with/without fringing reef), population size, and location.The first component of our research (undertaken simul-taneously) explored the contribution of fish to the dietsof women of reproductive age and infants and youngchildren [45]. We found that while fish was a centralcomponent of women’s diets, over 50% of mother-childpairs failed to meet the minimum recommended dietarydiversity. Furthermore, the introduction of fish to youngchildren’s complementary diets was delayed due to fearsand other concerns. This paper assesses the extent offood and nutrition security at the household level andresponses to food insecurity.Data collectionThe research applied mixed methods, with a combin-ation of qualitative and quantitative research activitiessuited to an interdisciplinary exploration of food and nu-trition security [30]. All field work was conducted be-tween September 2017 and May 2018; research activitieswere conducted during five trips to each village, withactivities sequenced to allow for comprehensive coverageof key thematic areas identified in the research frame-work as well as to allow for in-depth exploration ofemerging themes (see Table 1) [25]. The extended fieldwork period, and repetition of certain modules of thehousehold questionnaire, also allowed for the develop-ment of familiarity and rapport between the researchfield team and community members [59]. This teamcomprised the first author and three locally-engaged re-search assistants who acted as facilitators for researchactivities and translators. Research assistants receivedtraining on key elements of the research framework andthe data collection tools used. The household question-naire and interview / discussion guides were prepared inadvance and reviewed as part of the training to ensureGibson et al. BMC Public Health (2021) 21:355 Page 3 of 17key concepts were accurately translated and that appro-priate local terms were used. All activities were imple-mented in Indonesian or the local dialect (Bahasa Bajau),in which case one research assistant acted as a secondarytranslator.The introduction to research activities included an ex-planation of the purpose of the study, and later a sum-mary of activities undertaken to that point in time, andhow the instant activity contributed to the inquiry.Semi-structed interviews and focus group discussionswere conducted to gather information about historic andcontemporary livelihood activities across seasons,women’s household and community roles, historic andcontemporary meal patterns, and experiences of food in-security and coping/adapting strategies for times of foodinsufficiency. Semi-structured interviews were conductedwith key informants from the Regency’s food securityand fisheries agency and health department, communityhealth staff and village leaders, and with communitymembers (women, men, and those involved in fisheries).Key informants were identified based on their role (e.g.community nurse/midwife) and they subsequently iden-tified potential community participants based on topicsof interest. Additional participants were identifiedthrough purposive (i.e. to ensure coverage of differentfishing activities) and snowball sampling [29]. Interviewswere conducted in the participant's home or office andlasted for 30–75min. Focus group discussions were heldwith community members identified by key informants.An initial focus group discussion in each community ex-ploring seasonal food insecurity comprised a mix ofwomen and men, whereas subsequent groups were tar-geted depending on the topic and themes to be exploredand were conducted separately with either women ormen (e.g. ‘mothers with young children’, ‘males (openage) who fish’). Focus group discussions were held invillage meeting places and lasted for approximately 45min. Interviews were recorded unless the participant de-clined (n = 2). The audio recording was subsequentlytranscribed and translated by a research assistant. In thecase of interviews that were not recorded and focusgroup discussions, detailed notes were taken at the timeof the activity and then reviewed collaboratively by thefield research team to ensure that key themes, discussionpoints and contributed stories were accurately docu-mented. This, together with debriefing of research activ-ities with the research team, supported bracketingthroughout the study [92]. Key informants with publichealth roles provided feedback on preliminary findingsfrom the household questionnaire (see below). We ap-plied the principle of saturation in assessing topic cover-age, while multiple sequential research activities allowedfor triangulation [29, 87].A household survey using a structured questionnairewas conducted in each of the island villages. Eligiblehouseholds were those with at least one women of re-productive age (aged 18 to 49 years, hereafter referred toas women or mothers) and a child aged between 6months and 5 years of age. The questionnaire comprisedthree parts: (a) respondent and household socio-economic data, including men’s and women’s income-generating livelihood activities, asset ownership, andestimated monthly income and food expenditure; (b)food and nutrition security, including the Food Con-sumption Score Nutritional Quality Analysis [96, 97]and Household Food Insecurity Access Scale (HFIAS)[24] (see Data analysis below), both of which have beenvalidated as indicators of household food insecurity indifferent settings, including Indonesia [3, 23, 103]; and(c) household decision-making and health and nutritionknowledge. The questionnaire comprised a combinationof standard modules (e.g. access to drinking water andTable 1 Summary of field site characteristics and research activitiesResearch activities Field sites TotalFS 1 FS 2 FS 3 Labuan BajoPopulation / households a 1860 / 477 604 / 152 242 / 56 2706 / 685Eligible households b 186 52 25 263Household surveyJanuary 2018 36 20 10 66April 2018 34 15 10 59 cInterviews- Key informant 5 (3 M; 2 W) 3 (2 M; 1 W) 2 (1 M; 1 W) 6 (2 M; 4 W) 16 (8 M; 8 W)- Semi-structured 12 (0 M; 12 W) 6 (0 M; 6 W) 4 (0 M; 4 W) 2 (0 M; 2 W) 24 (0 M; 24 W)Focus group discussions 5 (8 M; 29 W) 2 (4 M; 10 W) 2 (6 M; 5 W) 9 (18 M; 44 W)M man, W womana estimate from village census information, October 2017; b estimate based on information obtained from local health volunteers; c participation in the secondround of the household survey was reduced, with two households declining to participate and the remaining households absent from the village during thesurvey periodGibson et al. BMC Public Health (2021) 21:355 Page 4 of 17sanitation, food and nutrition security indicators) whichwere locally-adapted through discussion with key infor-mants in accordance with relevant guidance documents,together with questions relevant to the study. The ques-tionnaire is available as Supplementary Material to Gib-son et al. [45]. The full questionnaire was conducted inJanuary 2018 during the wet season and part (b) was re-peated with the same households in late April duringthe dry season.1 This repetition allowed for the captureof seasonal variations in access to, availability of andconsumption of fish and other foods. In total, 66 house-holds participated in the survey. The sample size was de-termined based on the estimated prevalence of childstunting for Komodo District (49.31% [46]) and the esti-mated number of eligible households, sufficient to give astandard error of 12.5% at a 95% confidence interval[26]. A list of eligible households was prepared with theassistance of local health staff and, as Indonesian villagesare administratively divided into sections (RTs), five ran-domly selected eligible households from each sectionwere surveyed. The survey took between 45min and 1.5h to complete. The survey was piloted in a similar main-land community and minor amendments were made tosimplify rating scale questions.Data analysisFood consumption score nutritional quality analysisData on household food consumption was collectedbased on the module developed by [96, 97]). Themodule was pre-adapted using information about con-temporary dietary patterns collected in key informantinterviews, focus group discussions and a market sur-vey of locally available foods. Additional questionswere included about the type of fish consumed. A listmethod, in which the respondent is asked if anyonein her household has consumed foods from a particu-lar food group in the preceding 7 days, and the num-ber of days on which that food was consumed,followed by prompting about different meals andsnacks and examples of locally-available foods, wasused. The data were entered into a Microsoft Excelspreadsheet and the food consumption score was cal-culated following the prescribed method [96, 97].Descriptive statistics for household food consumptionscore (poor 0 ≤ 28; borderline 28.5 ≤ 42; acceptable >42), proportion of households consuming nutrient-dense foods, and frequency of household consumptionof nutrient-dense foods were calculated. The thresh-old for an acceptable household diet was adjustedupwards as recommended by [96, 97]), given frequentconsumption of sugar and oil. Frequency of consump-tion data are disaggregated as 0, 1–3, 4–6 and 7 days(rather than the recommended 0, 1–6 and 7 days) be-cause a high proportion of foods, especially vitamin Arich foods and fruits and vegetables, were reported tobe consumed on only 1–3 days of the recall period.While ‘fruits and vegetables’ are not a specific cat-egory in the methodology, we present this data togain a better understanding of consumption ofnutrient-dense foods.Household food insecurity access scaleData on household experiences of food insecurity withinthe access domain of food security was collected usingthe module developed by Coates et al. [24]. The modulecomprises nine condition questions across three do-mains of food insecurity ((i) anxiety and uncertainty; (ii)insufficient quality; (iii) insufficient food intake and itsphysical consequences) and asks the respondent aboutthe household’s experience over the last 4 weeks. Foreach affirmative response, the respondent is asked aboutthe frequency of occurrence of that experience, capturedas rarely (1–2 times in the past 4 weeks), sometimes (3–10 times), often (> 10 times). The data were entered intoa Microsoft Excel spreadsheet and descriptive statisticsfor the proportion of households experiencing eachcondition and domain, HFIAS score (range 0–27),and HFIAS prevalence (food secure, mildly, moder-ately and severely food insecure) were calculatedfollowing the prescribed method [24]. A food securehousehold experiences none of the food insecurity(access) conditions, or may just experience worry, butrarely; where as a severely food insecure householdexperiences a reduced quantity of food often, and/orexperiences any of the most severe conditions, suchas running out of food.Household wealthHousehold wealth was evaluated using a Material Stylesof Life scale based on the building materials of thehouse, access to electricity (none, purchased, ownsource), access to improved sanitation, and the presenceor absence of household assets (fan, television, mobilephone, tablet, fridge, couch/sofa set, washing machine,scooter) [42, 80]. These items were factor analyzed usingthe principal component method, and items with lowfactor loadings removed [21]. The first principal compo-nent axis explained 27.72% of the variation in wealthamong households. Households with higher wealth hadhomes with brick walls and cement floors, their ownsource of electricity and access to improved sanitation.1From the June to September, in the dry season (musim timur), theprevailing wind blows from the east, bringing little moisture andcalmer seas conditions. From December to March, in the wet season(musim barat), the prevailing wind blows from the west, bringinghigher rainfall and stormier weather. Transitional conditions occur inthe remaining months. In 2018, the dry season was well established byearly March.Gibson et al. BMC Public Health (2021) 21:355 Page 5 of 17The scale was weighted by the number of householdmembers and households were grouped into three wealthlevels: low (lowest 40%), middle, and high (highest 20%).Additional analyses were undertaken in SPSS (version24, IBM). Seasonal differences between mean householdfood consumption and HFIAS score were explored withpaired t-tests. Seasonal differences between the propor-tion of households in each food consumption score andHFIAS category were explored using Wilcoxon signed-rank tests. Seasonal differences between the frequency ofconsumption of key food groups and of foods withinthese food groups were explored using Wilcoxon signed-rank and sign tests. Differences between household’s ex-perience of the HFIAS domains and conditions were ex-plored using McNemar’s tests. Logistic generalizedlinear mixed models (binomial with logit link, withhousehold as a random intercept and variance compo-nent as covariance structure) were tested to assess theassociation between severely food insecure householdsand different socio-demographic factors, with a multi-variable model developed with confounders and vari-ables with p < 0.1 from the univariable model includedas predictors. Model diagnostics for the final multivari-able model included a low Akaike Information Criterionand residual diagnostics, model convergence and ab-sence of multicollinearity as indicated by variance infla-tion factors (VIF = 1.0). Two-tailed p values < 0.05 wereconsidered significant.Transcripts of the interviews and focus group dis-cussions, along with field notes, were entered intoNVivo Pro 12 (QSR). Review and analysis of data oc-curred parallel to the extended period of field work,allowing for refinement and extension of research ac-tivities to explore emerging themes [81]. We appliedcontent analysis to systematically analyze textual dataand interpret its meaning [31]. The first authorreviewed each data source numerous times to ensurefamiliarity and then coded the data deductively usingan unconstrained categorization matrix based onthemes (categories) and sub-themes drawn from theresearch framework [32] (see Supplementary Informa-tion: Table S1). Emergent sub-themes were added tothe matrix as necessary. A structured approach wasapplied in which data were coded by sets of themes(i.e. multiple pass), data within categories was com-pared, then linkages between themes and sub-themeswere evaluated [81]. This approach was appropriategiven that the broader aim of the research projectwas to assess evidence of the contribution of fish andsmall-scale fishing livelihoods to food and nutritionsecurity along Kawarazuka and Bene's [58] three path-ways [32]. Anonymized representative participantquotes (identified by reference code) are provided toevidence perceptions of and responses to food inse-curity [31].ResultsCharacteristics of householdsThe average age of female respondents to the householdsurvey was 29.7 years (SD +/− 6.7 years) (Table 2). Nearlyhalf of the women (48%) had not completed primaryschool, and 22.7% had attempted or completed a higherlevel of education. Households, comprising a collectionof people who regularly eat together and sleep under theone roof [50], typically comprised between 4 and 6members (59% of all households) (excluding childrenwho were boarding away from home). Larger householdsgenerally comprised a younger couple with children liv-ing with one set of parents, in which case the older fe-male retained responsibility for management ofhousehold monies and food provision and preparation,with the younger couple contributing towards householdexpenses and labor.The average number of income-generating livelihoodactivities per household was 2.24 (SD ± 1.08; range 1–5),with 43% of households pursuing two or more income-generating livelihood activities. Men’s livelihood strat-egies were centered on capture fishing and fish tradingactivities, with only 4.5% of households not engaged insmall-scale fisheries activities. Men participated in tendifferent capture fisheries livelihood activities, with fish-ing practices varying according to the target species andgear used. Women in 41% of households reported pur-suing an income-generating livelihood activity, typicallyhome-based activities such as making and selling trad-itional cakes. Other women took up community rolessuch as volunteer health workers and received a smallmonthly incentive payment.Approximately 17% of households were double bur-den households, with the mother classed as over-weight or obese and an index child having stuntedgrowth.Consumption of nutrient-dense foodsMost households appear to have acceptable access to ad-equate food, with 89 and 97% of households having an‘acceptable’ food consumption score for the wet and dryseason respectively (wet season: M = 54.95, SD ± 13.88,range: 22.5–85; dry season: M = 58.89, SD ± 10.98, range:29–84). The mean food consumption score was higherin the dry season (3.681, 95% CI [0.022, 7.340]). How-ever, when the consumption frequency of nutrient-densefood groups is disaggregated, we found that most house-holds consumed protein and iron rich foods every day,and vitamin A rich foods less frequently (Fig. 1).Protein-rich foods, principally fish, were consumed onall 7 days of the seven-day recall period by 86% ofGibson et al. BMC Public Health (2021) 21:355 Page 6 of 17households in the wet season and 98% of households inthe dry season (Fig. 2a). Consumption of heme iron richfoods was also frequent, with 82% of households con-suming heme iron rich foods on all 7 days of the seven-day recall period in the wet season and 95% of house-holds in the dry season. Again, fish was the most im-portant source of heme iron in household diets (Fig. 2b).Consumption of vitamin A rich foods was less frequent,with only 35 and 21% of households consuming vitaminA rich foods on all 7 days of the wet and dry seasonseven-day recall periods. Conversely, a higher proportionof households consumed vitamin A rich foods on only1–3 days of the respective wet and dry season seven-dayrecall periods. The most commonly consumed vitaminA rich foods were eggs and dark green leafy vegetables(Fig. 2c). Consumption of vitamin A rich foods waslikely higher in the wet season because eggs were usedas a substitute when fish were not available and wereprovided to young children when only a non-preferredspecies of fish (e.g. squid) was available. Overall con-sumption of fruits and vegetables was very low in boththe wet and dry seasons (Fig. 2d). Collectively, consump-tion of vitamin A rich foods (z = − 4.26, p < 0.0005) andfruits and vegetables (z = − 2.27, p = 0.023) were statisti-cally significantly higher in the wet season.Perceptions of food insecurity experienceMany of the households surveyed experienced varyingdegrees of food insecurity. Only 15 and 22% of house-holds were classed as food secure during the wet anddry seasons respectively (Fig. 3). Around one third ofhouseholds were classed as severely food insecure inboth seasons, with an additional third of householdsmoderately food insecure in both seasons. Overall, re-ported experiences of food insecurity were higher in thewet season (z = 2.24, p = 0.025).A majority of households reported experiencing thedomains ‘anxiety and worry’ about access to food (79%wet season, 69% dry season), and an ‘insufficient qualityof food’ (79% wet season, 71% dry season) (Fig. 4). In in-terviews numerous women said they worried about se-curing food; for example, we often worry (IF9-FS1-2017);worrying about your children, whether they have some-thing to eat or not (IF6-FS1-2017). The proportion ofhouseholds that reported experiencing the different con-ditions of food insecurity was higher in the wet season.Table 2 Socio-demographic characteristics of female respondents and householdsCharacteristics Mean ± SD or n (%) NMaternal characteristicsMaternal age, years 29.7 ± 6.7 66Highest level of schooling completed 66Some primary 32 (48.5)Completed primary (6 years) 19 (28.8)Some or completed secondary, or further education 15 (22.7)Mother has income-generating livelihood activity 26 (39.4)Household characteristicsNumber of household members 4.69 ± 1.75 66Household livelihood activities (no.) 66All livelihood activities 2.24 ± 1.08Small-scale fisheries livelihood activities 1.55 ± 0.9Women’s livelihood activities 0.45 ± 0.41Other non-fishing livelihood activities 0.24 ± 0.56Material Styles of Life scale (wealth) 0, ± 1Range − 1.21805, 2.2464366Lowest wealth 24 (36.4)Middle wealth 30 (45.5)Highest wealth 12 (8.2)Double burden households a 9 (16.98) 53Recipient of RASTRA b 14 (21.2) 66a households were classed as ‘double burden’ when the mother has a BMI class of overweight or obese and the child has stunted growth; anthropometry datawas not collected from 3 women who disclosed a pregnancy and 10 children; b RASTRA is an Indonesian Government program providing supplemental rice forpoor householdsGibson et al. BMC Public Health (2021) 21:355 Page 7 of 17Overall, household perception of severity of experienceof food insecurity was lower in the dry season, with asmaller proportion of households reporting experiencingthe different conditions often (i.e. more than 10 timesover the last 30 days). Reported frequency of experienceof ‘worry or anxiety’ (z = − 3.39, p = 0.0001), having to‘eat foods that really did not want to eat’ (z = − 3.09, p =0.002), ‘eat fewer meals in one day’ (z = − 2.19, p =0.029), and having ‘no foods of any kind in the house-hold due to lack of resources’ (z = − 1.97, p = 0.048) wereall significantly higher in the wet season.Factors affecting household perceptions of foodinsecurity experienceThe association between a household being severely foodinsecure and numerous independent variables wasassessed: maternal characteristics (age, level of educa-tion, livelihood, mother having adequate dietary diver-sity), household characteristics (number householdmembers, number livelihood activities, material style oflife score, double burden household, household receivesRASTRA), and season. The final model showed that thestrongest predictors of households being severely foodinsecure were mother having low education (not havingcompleted primary school) and households having a lowMSL score (i.e. having low material wealth) (Table 3).Responses to food insufficiencyHouseholds employed a range of immediate and short-term consumption strategies and longer-term non-consumption strategies in anticipation of or in responseto a shortfall in food (Table 4). The primary consump-tion strategies employed were changes in diet andincreasing short-term food supply. Women responded toa shortfall in food by purchasing cheaper and less-preferred foods. As one woman from field site 1explained: if there is no money, we eat noodles and eggs,because the fish here are expensive, the vegetables arealso expensive (IF9-FS1-2018). In field site 2 somewomen buy dried cassava from a seller from Ende andalternate with rice in meals (FG1-FS2-2017); anotherwoman explained: if [I] don’t have rice, I grind downcorn to make porridge or boil and mash banana (HSF4-FS2-2017). Women also used their social capital to se-cure food from friends, neighbors and relatives; sharingof excess fish was common, and one woman revealed:yesterday my sister brought a large bowl of vegetablesoup that had pumpkin and carrot in it and my familyshared it (HSF1-FS2-2018). The purchasing of food oncredit was also commonplace. Women obtained stapleand other foods (e.g. flour, sugar) on credit from theirhusband’s fishing boss, whom they described as stockpil-ing staples during the wet season, and other kiosk ven-dors. One third of households who had obtained loansfrom a boss had done so to secure food or meet othergeneral household expenses. One woman explained: myability is that if we have not enough money, I will try toowe the stall [and] I do selling cakes to cover our lack ofmoney … I will owe to someone; I don’t care what peoplesay, they don’t know the situation (IF6-FS1-2017). TheFig. 1 Proportion of households consuming nutrient-rich food groups in 7-day recall periods, by frequency category. Figure 1 shows that mosthouseholds were frequent consumers of protein and iron-rich food groups, and less frequent consumers of vitamin A rich foods, and fruitsand vegetablesGibson et al. BMC Public Health (2021) 21:355 Page 8 of 17ability to obtain fruits and vegetables on credit from vil-lage vendors was identified by women as one of the rea-sons for not obtaining fruit and vegetables from thelarger markets in Labuan Bajo. Resort to wild foods,such as gleaning for marine resources, was not commondespite the maritime traditions of the Sama-Bajau.Women did occasionally harvest ‘kelor’ (Moringa olei-fera) when they could not obtain other leafy greens:moringa leaves grow here so that would be our onlyvegetable [in the wet season] (IF4-FS1-2017). Overall,in times of food insufficiency women produced sim-pler less-nutritious meals comprising mainly rice or asubstitute staple, with a small (or no) accompaniment.As one woman explained: sometimes [we] will just eatrice for a meal, when don’t have fish or vegetables(HSF1-FS1-2017).Households employed several non-consumptionstrategies. Fisher-husbands altered or re-directed theirfishing practice while at sea depending on their suc-cess in harvesting higher-value export fish. If fishershad been unsuccessful, and hence had generated noincome, they would re-direct their fishing effort tothe harvest of small reef fish so as to ensure theywere able to provide fish for their family. A fisher ex-plained: the catch is uncertain, if the blessing is will-ing then I would have a lot of catch, but if theblessing is not willing, even for consumption would behard to find (IM3-FS2-2018). Women also sought toincrease their ability to access food by establishinghome-based food or trading businesses. These smallinformal businesses were typically established withfood stuffs or goods obtained on credit, and thus thewomen risked falling into debt. For example, onewoman explained: I also sell some things which couldbe paid by installment... I see that as a business op-portunity and then settle up the installment details …the payment could be settled up to two or 3 yearsafter my merchandise is sold … I see a lot of peoplerunning the exact business as I do and I think I amthe most patient creditor (IF2-FS1-2017). Around two-fifths (43.6%) of households kept free-roaming chick-ens or goats which could be sold for cash when re-quired. Less than one third (29%) of householdsaccrued savings (in the form of cash or gold jewelry)Fig. 2 Average reported frequency of consumption of nutrient-rich food groups: protein, heme iron, vitamin A, and fruits and vegetables. Thepanels in Fig. 2 show the average reported consumption frequency of foods within nutrient-dense food groups by households during the seven-day recall periods. Fish is the most frequently consumed protein and heme iron rich food, while eggs are an important source of vitamin A. Darkgreen leafy vegetables are an important source of vitamin A and the most frequently consumed food group among fruits and vegetables. Notes:n = 66 wet season; n = 59 dry season; * p < 0.05, ** p < 0.01, *** p < 0.001; there were statistically significant median seasonal differences in thereported consumption of pulses (z = 2.58, p = 0.010), fish (z = 2.22, p = 0.027), eggs (z = − 6.17, p < 0.0005), orange vegetables (z = 2.09, p = 0.027),dark green leafy vegetables (z = − 2.59, p = 0.010), other vegetables (z = − 2.86, p = 0.004), orange fruits (z = − 4.97, p < 0.0005) and other fruits(z = 2.83, p = 0.005)Gibson et al. BMC Public Health (2021) 21:355 Page 9 of 17from their fishing and other business activities whichcould then be relied upon in times of foodinsufficiency.DiscussionThis study presents findings from an exploratory assess-ment of food and nutrition security in three specialisedfishing communities in Komodo District, NTT, easternIndonesia. We found that households appear at first tohave adequate access to consumption of diverse food.However, the typical household dietary patterncomprised frequent consumption of the staple rice andregular consumption of fish, and only occasional con-sumption of vitamin A rich foods and fruits andvegetables in general. Fish were the primary dietarysource of protein and heme iron; a wide range of fishwere consumed, including reef-associated finfish such asemperor, rabbitfish and grouper, and small pelagics suchas anchovy and sardines. Studies indicate that fish canbe an important dietary source of vitamin A [11, 85].However fish are not included in the ‘vitamin A richfood group’ used to construct the Food ConsumptionScore for nutritional quality analysis, perhaps reflectingthe indicator’s historical development in Sub-SaharanAfrica where per capita fish consumption is among thelowest in the world [38]. The inclusion of fish is ham-pered by complexity arising due to the form, contentand bioavailability of vitamin A differing among fish spe-cies and also affected by a range of ecological processes[16, 84]. Despite recent efforts in other countries [11, 79,83], there is limited nutritional data available for com-monly consumed fish in Indonesia. The Food Compos-ition Table for Indonesian lacks sufficient detail, listingonly a handful of fish (for example ‘anchovy’, ‘fish’, ‘fish,sea’ and ‘fish, tuna’) and fish dishes, although over 870species of bony fish are marketed [89, 99]. This lack ofinformation, applying equally to other key micronutri-ents and minerals such as iron and zinc, is compoundedby limited understanding of the impact of post-harvesthandling and processing and cooking methods on thenutrition quality of fish. In the case study communities,fish were observed being processed using methods thatraised food safety concerns, further highlighting thecomplex interplay of factors associated with ensuring ac-cess to adequate, nutritious and safe foods for all.Household consumption of fruits and vegetables in thecommunities studied varied seasonally in accordancewith local availability and corresponding affordability. Asmall number of nutrient-dense moringa trees (Moringaoleifera, kelor) were grown by individual households ineach community. Moringa appear to be underutilized asa versatile and nutrient-dense food source, particularlygiven that little else was successfully cultivated locally.Fruits were considered as a snack food whereas vegeta-bles were typically consumed in small portions as a sidedish or incorporated sparingly in stir-fried dishes orsoups. This appears consistent with other dietary pat-terns across Indonesia, with data at the national level in-dicating that Indonesians consume less than half therecommended daily amount of fruits and vegetables [9,94]. Infrequent consumption of fruits and vegetableswere also evident in the 24-h recall dietary quality datawe collected for women of reproductive age and infantsand young children [45]. Analysis of this data found thatboth the mother and child in one half of mother-childpairs surveyed had consumed fruits and vegetables inthe 24-h recall periods (53% in the wet season and 49%in the dry season) and, that in 88% of mother-child pairsFig. 3 Proportion of households experiencing food insecurity during the wet and dry seasons. Figure 3 shows the proportion of householdsexperiencing the different degrees of food security, as determined by reported severity of experience of the different conditionsGibson et al. BMC Public Health (2021) 21:355 Page 10 of 17neither the mother nor child had consumed vitamin Arich fruits or vegetables. Other studies from Indonesiahave shown that diets lacking diversity increase the riskof vitamin A and iron deficiency for infants and youngchildren, female adolescents, and women of reproductiveage, suggesting that women and children may be suscep-tible to micronutrient deficiencies despite the frequentconsumption of fish [8, 64, 86]. Moreover, as is also ob-served in Albert et al. [1]‘s study in the Solomon Islands,the dietary quality data contrast with the initial impres-sion given by the Food Consumption Score. This sug-gests that the cutoff scores used for poor, borderline andacceptable diets in contexts where there is frequent con-sumption of fish (and other protein foods) should beFig. 4 Proportion of households experiencing different domains and conditions of food insecurity in the wet and dry seasons. Figure 4 showsthe proportion of households experiencing the domains of food insecurity (access) (all) and the proportion of those households experiencing thecondition of food insecurity (access) within each domain. While many households reported experiencing different domains of food insecurity inboth the wet and dry season, the severity of experience was higher in the wet season, with households more likely to experience anxiety andworry about food, and insufficient quality of foodGibson et al. BMC Public Health (2021) 21:355 Page 11 of 17adjusted further upwards. This anomaly reinforces theimportance of selecting an appropriate combination offood and nutrition security indicators, depending on thepurpose of the study and feasibility of data collectiongiven available resources and other constraints [37, 61].A healthy diet encompasses a balanced, diverse andappropriate selection of foods, ensuring that the needfor macro- and micronutrients are met given a person’sgender, age, physical activity level and physiological state[40]. Increasing dietary diversity is one of the core mes-sages of Indonesia’s revised dietary guidelines [75] and isincluded as an objective of the food-related policyframework (National Medium-Term Development Plan2015–2019, Strategic Policy for Food and Nutrition2015–2019, National Action Plan for Food and Nutrition2017–2019). While recent progress has been made withrespect to increasing the consumption of fish [2], con-sumption of fruits and vegetables declined by around 4% between 2012 and 2016 and continues to fall, in linewith dietary transitions occurring in many low- andmiddle-income countries [94]. There is a substantial dif-ference in the frequency of consumption of fruits andvegetables between Indonesian households in the lowestand highest income quintiles [94]. A recent assessmentfound that 38% of Indonesian households could not af-ford a staple-adjusted nutritious diet, increasing to 68%of households in NTT Province where nearly 60% ofrural households’ monthly expenditure is on food [12,98]. Low levels of fruit and vegetable consumption havebeen reported in small island developing states acrossthe Indo-Pacific region, largely due to cost and afford-ability but also changing taste preferences, convenienceand environmental challenges [1, 19, 33, 57]. Availabilityand affordability are key factors influencing householdpurchasing decisions, with low income households tend-ing to focus on consumption of sufficient energy-densestaple foods to meet calorie needs [88]. Efforts toincrease dietary diversity are also influenced by tastepreferences, food habits and taboos, low nutritionalawareness, convenience, food safety concerns and chan-ging lifestyles [56, 88]. We also found that women servedother members of their household before themselvesand relied upon the advice of women elders and trad-itional midwives rather that community health personnel[45]. These factors can lead to inequalities in intra-household distribution of nutrient-dense foods, whichcan be masked by studies at the household level [49].There is thus a critical need to further explore and ad-dress the barriers to consumption of nutrient-densefoods in the communities in this study area.The households included in our study reported highlevels of perceived food insecurity, with household per-ceptions of food security significantly higher in the dryseason. Food insecurity was likely higher in the wet sea-son due to poor weather conditions which kept fishersashore resulting in there being less fish harvested forsubsistence consumption or sold for income. Poor wea-ther also meant that small fruit and vegetable vendorscould not travel between the islands and mainland mar-kets. Only a small proportion of households reported themore severe food insecurity condition experiences, suchas ‘not having food of any kind in the household’ and‘going a whole day and night without eating’, althoughthese were rare occurrences. Fabinyi et al. [35] identifiedsimilar experiences in fishing communities in thePhilippines. A higher level of food insecurity was associ-ated with a low level of maternal education and lowermaterial styles of life score, a proxy for householdwealth. These factors have previously been identified asrisk factors for food insecurity and children’s micronu-trient deficiencies [48, 90]. Empowering women througheducation is argued to be the single most important de-terminant of food security, with women with higherlevels of education likely to delay having children, haveTable 3 Association between a household being severely food insecure and explanatory factorsFactor Univariable model Multivariable modelOdds ratio 95% CI p value Odds ratio 95% CI p valueMaternal age (years) 0.9 0.9–1.0M hasn’t completed primary school 0.3 0.1–0.6 0.005 ** 3.8 1.5–9.9 0.007 **Mother has livelihood activity 1.1 0.4–2.9Mother has adequate dietary diversity 1.0 0.4–2.8No. household members 1.1 0.8–1.5No. household livelihoods 1.3 0.8–2.1Material Styles of Life score (scale) 0.5 0.3–0.8 0.011 * 0.5 0.3–0.9 0.020 *Double burden household 0.5 0.1–2.7Household receives RASTRA 3.3 1.1–10.0 0.039 *Season 0.8 0.4–1.5CI Confidence Interval; p value only shown when significant; * p < 0.05 and ** p < 0.01Gibson et al. BMC Public Health (2021) 21:355 Page 12 of 17increased opportunity to participate in the work force,greater decision-making capability and the ability to in-fluence household purchasing to support improved nu-trition outcomes [55, 90]. Darling [27] and Fiorella et al.[43] found household wealth was associated with higherlevels of food security in inland and coastal fishing com-munities in Kenya respectively, irrespective of the house-hold pursuing fishing livelihoods.In these specialised fishing communities, food inse-curity was a cyclical and seasonal phenomenon, withthe flow of fish, income and food linked to the typeof fishing activity pursued. For many households, foodinsecurity reflected the lunar cycle, with night fishingpractices such as spearfishing and lift-net fishing sig-nificantly reduced or ceasing during each full moonphase. Households employed a range of consumptionand non-consumption strategies to manage throughtimes of food insecurity; these include four commonlyidentified coping strategies: dietary change, food-seeking (including borrowing, purchasing on creditand reliance on wild foods), household structure, andrationing [65, 66]. However the strategies were not“short-term responses to an immediate and inhabitualdecline in access to food” [28], but rather routine in-surance and adaptive strategies in response to the va-garies of the small-scale fisheries activities pursuedand the broader socio-economic context. The incomegenerated by fishing, particularly for poorer fishinghouseholds without fishing capital (boats, engines,gear), was too low to allow for savings, leaving thefisher and his household reliant on patron boatowners for work and other support such as loans tocover food or medical expenses [35, 41, 73]. Whilenumerous studies have noted the importance of liveli-hood diversification strategies in increasing householdresilience [47, 71], such options are limited inspecialised fishing communities by the pervasivenessof patron-client relationships, geography, communitysize and cultural identity associated with fishing as a‘way of life’ [67]. None of the households in the studycommunities engaged in cropping, kitchen gardenswere uncommon, soils were poor and fresh water lim-ited. Some fisher-wives created small food-based orpetty-trade businesses, however, the vagaries of fishingand the flow of money within the communities im-pacted these businesses too, leaving the women vul-nerable to debt. The range of strategies pursued byhouseholds highlights their high level of risk to en-titlement failure, and vulnerability to continued foodinsecurity.Strengths and limitationsThis research places a spotlight on the experiences offood and nutrition security in remote rural specialisedfishing communities, a vulnerable group which hasbeen overshadowed by a consistent focus on food se-curity in agricultural small-holder households. Severallimitations should be considered. As a small cross-sectional case study, the results relate to householdsin these communities comprising a woman of repro-ductive age and a child aged between 6 months and 5years, and therefore may not be generalizable to theTable 4 Strategies employed by households in response to food insufficiencyType of strategy ExamplesConsumption strategiesChange diet Consume cheaper / less-preferred foods, such as noodles and egg instead of preferred rice and fishIncrease short-term food supply Borrow (or in kind) food from friends, neighbors or relativesPurchase food on credit from boss or kiosk ownerGlean for marine resourcesHarvest locally-growing kelor (Moringa oleifera)Reduce number of people to be fed Send children to relatives’ homes for main mealsRation food supplies Reduce portion size for all family membersReduce maternal portion size (eat only after other family members)Skip one or more meals in a dayNon-consumption strategiesAlteration of income-earning patterns Fisher abandons income-earning fishing activity to ensure he harvests fish for household consumptionFemale household member borrows money to establish a home-based food or trading businessSale of small assets Sell small livestock (i.e. goats)Sell or pawn gold jewelrySavings Use cash savings accrued during dry seasonGibson et al. BMC Public Health (2021) 21:355 Page 13 of 17wider Indonesian population. The analysis drew onmaternal-reported food consumption and experienceof food insecurity data which may be subject to recallerror and, despite careful explanation of the purposeof the study, social desirability bias. Consumption offruits and vegetables are driven by seasonal availabilityand greater access due to lower prices. While we col-lected data in periods covering the major seasonsfrom a fisheries perspective, neither survey period co-incided with the local mango season which occursfrom October to December. A repeat survey duringthat period may have produced elevated food con-sumption and dietary diversity scores due to morefrequent consumption of mango, a vitamin A richfruit. We acknowledge that the quality of food con-sumption data collected using questionnaires is im-perfect and that quantitative dietary assessment withadditional biochemical measures would allow for amore accurate assessment of nutrition status. Finally,research activities were undertaken by a multi-lingualfield research team, so our methodology incorporatedfrequent cross-checking and the use of probing ques-tions to clarify understanding and further explore re-sponses. Transcripts were transcribed verbatim andchecked for correspondence with contemporaneousnotes, but unfortunately resources and timing did notallow for rechecking of transcribed material with re-search participants. While data were not co-coded,regular and reflexive debriefing supported bracketing.ConclusionThis study assessed food and nutrition security in threespecialised fishing communities in Komodo District,eastern Indonesia. We found that while households ap-peared to have access to diverse foods, and fish were im-portant dietary sources of protein and heme iron,consumption of nutrient-dense fruits and vegetables wasinfrequent, leaving households vulnerable to micronu-trient deficiency. We also found that households re-ported experiencing high levels of food insecurity,escalating in the wet season. Household membersresponded to shortfalls in food by employing a range ofinsurance and adaptive strategies, however these werenutritionally and economically unsustainable [28]. Thesefindings highlight the vulnerability of specialised fishingcommunities, particularly given their linkages to inter-national markets and the potential impacts of a changingclimate. Enhancing food and nutrition security in specia-lised fishing communities requires a culturally-sensitivecross-sectoral response that strengthens livelihood op-portunities, supports and/or provides improved financialliteracy and affordable credit, and supports local produc-tion of higher-value fish-based foods and increased ac-cess to nutrient-dense fruits and vegetables.Supplementary InformationThe online version contains supplementary material available at https://doi.org/10.1186/s12889-021-10248-3.Additional file 1: Table S1. Outline of research framework, withthemes and sub-themes used to code and analyse data.AbbreviationsHFIAS: Household Food Insecurity Access Scale; NTT: Nusa Tenggara Timur;RT: Rukun tetangga (Bahasa Indonesia), neighborhood groupAcknowledgementsWe thank Neky Nitbani, Enggar Stitek and Apry Leokuna (research assistants),Mirjam Kaestli (Charles Darwin University), and each of the village leaders,community members and respondents from the study communities andassociated area for their openness, hospitality and participation in researchactivities. We also thank the editors of BMC Public Health and threeanonymous reviewers for their valuable feedback.Authors’ contributionsEG: Conceptualization, Methodology, Investigation, Formal analysis, Writing –original draft, Writing – review and editing; NS: Resources, Fundingacquisition, Writing – review and editing; TS: Writing – review and editing;DA: Writing – review and editing. All authors read and approved the finalmanuscript.FundingEG was in receipt of an Australian Government Research Training Scholarshipand received additional funding from Charles Darwin University and an ACIAR Small Research Activity. The funders played no role in study design, datacollection and analysis, decision to publish or preparation of the manuscript.The research formed part of EG’s doctoral thesis.Availability of data and materialsThe datasets used and/or analysed, and the interview and discussion guidesused, during the current study are available from the corresponding authoron reasonable request.Ethics approval and consent to participateThis study was approved by the Human Research Ethics Committee atCharles Darwin University (H17085). The Indonesian Ministry of Research,Technology and Higher Education provided research clearance (247/SIP/FRP/E5/Dit.KI/IX/2017), with additional permissions obtained from NTT Provincialand Regency officials and village leaders. All respondents provided writteninformed consent to participate in the study, which was recorded on surveyquestionnaires or interview and focus group discussion participant forms.Parental consents encompassed collection of their child’s anthropometricdata. The names of the case study villages are not disclosed in this paper tomaintain community confidentiality.Consent for publicationNot applicable.Competing interestsThe authors declare no competing interests.Author details1Research Institute for the Environment and Livelihoods, Charles DarwinUniversity, Ellengowan Drive, Darwin, Northern Territory, Australia.2Department of Forest and Conservation Sciences, University of BritishColombia, 2424 Main Mall, Vancouver, Canada. 3Centre for InternationalForestry Research, Bogor, Indonesia. 4Research Centre for Society andCulture, Indonesia Institute of Sciences, Jl.Jend Gatot Subroto 10, Jakarta,Indonesia.Gibson et al. BMC Public Health (2021) 21:355 Page 14 of 17Received: 15 July 2020 Accepted: 14 January 2021References1. Albert J, Bogard JR, Siota F, McCarter J, Diatatlau S, Maelaua J, et al.Malnutrition in rural Solomon Islands: an analysis of the problem andits drivers. Matern Child Nutr. 2020;16(12):12. https://doi.org/10.1111/mcn.12921.2. Ambari M. The consumption of fish per capita is encouraged to reach 50kilograms, how? (Konsumsi Makan Ikan Per Kapita Didorong Capai 50Kilogram, Caranya Bagaimana?) Mongabay; 2018. https://www.mongabay.co.id/2018/01/23/konsumsi-makan-ikan-per-kapita-didorong-capai-50-kilogram-caranya-bagaimana/. Accessed 22 Apr 2019.3. Ashari C, Khomsan A, Baliwali Y. HFIAS validation in measuring foodinsecurity: case in urban and rural households in South Sulawesi. J NutrFood Res. 2019;42(1):11–20. https://doi.org/10.22435/pgm.v42i1.2417.4. Barange M, Merino G, Blanchard JL, Scholtens J, Harle J, Allison EH, et al.Impacts of climate change on marine ecosystem production in societiesdependent on fisheries. Nat Clim Chang. 2014;4:211–6. https://doi.org/10.1038/NCLIMATE2119.5. Bene C, Barange M, Subasinghe R, Pinstrup-Andersen P, Merino G, HemreGI, et al. Feeding 9 billion by 2050 - putting fish back on the menu. FoodSecurity. 2015;7(2):261–74. https://doi.org/10.1007/s12571-015-0427-z.6. Bene C, Hersoug B, Allison EH. Not by rent alone: analysing the pro-poorfunctions of small-scale fisheries in developing countries. Dev Policy Rev.2010;28(3):325–58.7. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al.Maternal and child undernutrition and overweight in low-income andmiddle-income countries. Lancet. 2013;2013(382):427–51. https://doi.org/10.1016/S0140-6736(13)60937-X.8. Blaney S, Februhartanty J, Sukotjo S. Feeding practices among Indonesianchildren above 6 months of age: a literature review on their magnitude andquality (part 1). Asia Pac J Clin Nutr. 2015;24(1):16–27. https://doi.org/10.6133/apjcn.2015.24.1.13.9. BMKG. Food security monitoring bulletin Indonesia: special focus: fruit andvegetables consumption and production trends. Jakarta; Government ofIndonesia; 2017.10. Bogard JR. Will fish be part future healthy and sustainable diets? LancetPlanet Health. 2019;3(4):e159–60.11. Bogard JR, Thilsted SH, Marks GC, Wahab A, Hossain MAR, Jakobsen J, et al.Nutrient composition of important fish species in Bangladesh and potentialcontribution to recommended nutrient intakes. J Food Compos Anal. 2015;42:120–33.12. BPS - Statistics Indonesia. Consumption expenditure of population ofIndonesia by province, based on the march 2016 SUSENAS. Jakarta;Government of Indonesia; 2016.13. BPS West Manggarai Regency (2018). Manggarai Barat Regency in Figures,BPS Kabupaten Manggarai Barat.14. Burchi F, De Muro P. From food availability to nutritional capabilities:advancing food security analysis. Food Policy. 2016;60:10–9.15. Burke L, Reytar K, Spalding M, Perry A. Reefs at risk revisited in the coraltriangle; 2012. p. 86.16. Chakraborty K, Joseph D, Chakkalakal SJ, Vijayan KK. Inter annual andseasonal dynamics of amino acid, vitamin and mineral composition ofSardinella longiceps. J Food Nutr Res. 2013;1(6):145–55. https://doi.org/10.12691/jfnr-1-6-6.17. Charlton KE, Russell J, Gorman E, Hanich Q, Delisle A, Campbell B, et al. Fish,food security and health in Pacific Island countries and territories: asystematic literature review. BMC Public Health. 2016;16:26. https://doi.org/10.1186/s12889-016-2953-9.18. Cheung WWL, Lam VWY, Sarmiento JL, Kearney K, Watson R, Zeller D, et al.Large-scale redistribution of maximum fisheries catch potential in the globalocean under climate change. Glob Chang Biol. 2010;16:24–35. https://doi.org/10.1111/j.1365-2486.2009.01995.x.19. Choy CC, Desai MM, Park JJ, Frame EA, Thompson AA, Naseri T, et al. Child,maternal and household-level correlates of nutritional status: a cross-sectional study among young Samoan children. Public Health Nutr. 2017;20(7):1235–47. https://doi.org/10.1017/S1368980016003499.20. Cinner JE, Daw T, McClanahan TR. Socioeconomic factors that affectartisanal fishers' readiness to exit a declining fishery. Conserv Biol. 2009;23(1):124–30. https://doi.org/10.1111/j.1523-1739.2008.01041.x.21. Cinner JE, McClanahan TR, Wamukota A. Differences in livelihoods,socioeconomic characteristics, and knowledge about the sea betweenfishers and non-fishers living near and far from marine parks on the Kenyancoast. Mar Policy. 2010;34:22–8. https://doi.org/10.1016/j.marpol.2009.04.003.22. Cisneros-Montemayor AM, Pauly D, Weatherdon LV, Ota Y. A globalestimate of seafood consumption by coastal indigenous peoples. PLoS One.2016;11(12):16.23. Coates J, Frongillo EA, Rogers BL, Webb P, Wilde PE, Houser R.Commonalities in the experience of household food insecurity acrosscultures: what are measures missing. J Nutr. 2006;136(Supplement):1438S–48S.24. Coates J, Swindale A, Bilinsky P. Household food insecurity access scale(HFIAS) for measurement of household food access: indicator guide. 3rd ed.Washington, D.C.: FHI360/FANTA; 2007.25. Creswell JW. Research design: qualitative, quantitative and mixed methodsapproaches. 3rd ed. USA: SAGE Publications; 2009.26. Daniel WW, Cross CL. Biostatisics: a foundation for analysis in the healthsciences. 10th ed. USA: Wiley; 2013.27. Darling ES. Assessing the effect of marine reserves on household foodsecurity in Kenyan coral reef fishing communities. PLoS One. 2014;9(11):e113614. https://doi.org/10.1371/journal.pone.0113614.28. Davies S. Are coping strategies a cop out? IDS Bull. 1993;24(4):60–72.29. Denscombe M. The good research guide for small-scale social researchprojects. 2nd ed. Philadelphia: Open University Press; 2003.30. Drimie S, McLachlan M. Food security in South Africa - first steps toward atransdisciplinary approach. Food Security. 2013;5:217–26. https://doi.org/10.1007/s12571-013-0241-4.31. Elo S, Kaariainen M, Kanste O, Polkki T, Utriainen K, Kyngas H. Qualitativecontent analysis: a focus on trustworthiness. SAGE Open. 2014;2014:1–10.https://doi.org/10.1177/2158244014522633.32. Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15. https://doi.org/10.1111/j.1365-2648.2007.04569.x.33. Eme PE, Kim ND, Douwes J, Burlingame B, Foliaki S, Wham C. Arehouseholds in Kiribati nutrition secure? A case study of South Tarawa andButaritari. Food Nutr Bull. 2020;16. https://doi.org/10.1177/0379572119891024.34. Fabinyi M. Food and water insecurity in specialised fishing communities:evidence from the Philippines. Nat Res Forum. 2018;42(4):243–53. https://doi.org/10.1111/1477-8947.12148.35. Fabinyi M, Dressler WH, Pido MD. Fish, trade and food security: movingbeyond ‘availability’ discourse in marine conservation. Hum Ecol. 2016;45(2):177–88. https://doi.org/10.1007/s10745-016-9874-1.36. Fanzo J. Healthy and sustainable diets and food systems: the key toachieving sustainable development goal 2. Food Ethics. 2019;4:159–74.https://doi.org/10.1007/s41055-019-00052-6.37. FAO. Compendium of indicators for nutrition-sensitive agriculture. Rome:FAO; 2016. p. 60.38. FAO. The state of world fisheries and aquaculture 2018: meeting thesustainable development goals. Rome: FAO; 2018. p. 227.39. FAO, IFAD, UNICEF, WFP, & WHO. The state of food security and nutrition inthe world 2018: building climate resilience for food security and nutrition.Rome: FAO; 2018. p. 202.40. FAO, IFAD, UNICEF, WFP, & WHO. The state of food security and nutrition inthe world: safeguarding against economic slowdowns and downturns.Rome: FAO; 2019. p. 239.41. Ferrol-Schulte D, Ferse SCA, Glaser M. Patron-client relationships, livelihoodsand natural resource management in tropical coastal communities. OceanCoast Manag. 2014;100:63–73. https://doi.org/10.1016/j.ocecoaman.2014.07.016.42. Filmer D, Pritchett LH. Estimating wealth effects without expenditute data -or tears: an application to educational enrollments in states of India.Demography. 2001;38(1):115–32.43. Fiorella KJ, Hickey MD, Salmen CR, Nagata JM, Mattah B, Magerenge R, et al.Fishing for food? Analyzing links between fishing livelihoods and foodsecurity around Lake Victoria, Kenya. Food Security. 2014;6:851–60. https://doi.org/10.1007/s12571-014-0393-x.44. GBD 2017 Diet Collaborators. Health effects of dietary risks in 195 countries,1990-2017: a systematic analysis for the global burden of disease study2017. Lancet. 2019;393:1958–72. https://doi.org/10.1016/S0140-6736(19)30041-8.45. Gibson EC, Stacey N, Sunderland TCH, Adhuri DS. Dietary diversity and fishconsumption by mothers and their children in fisher households in KomdoGibson et al. BMC Public Health (2021) 21:355 Page 15 of 17District, eastern Indonesia. PLoS One. 2020;15(4). https://doi.org/10.1371/journal.pone.0230777.46. Government of NTT Province, Food Security Council, Ministry of Agriculture,& WFP (2015). Food Security and Vulnerability Atlas NTT 2015.47. Hanazaki N, Berkes F, Seixas CS, Peroni N. Livelihood diversity, food securityand resilience among the Caiçara of coastal Brazil. Hum Ecol. 2013;41(1):153–64. https://doi.org/10.1007/s10745-012-9553-9.48. Harding KL, Aguayo VM, Masters WA, Webb P. Education and micronutrientdeficiencies: an ecological study exploring interactions between women’sschooling and children’s micronutrient status. BMC Public Health. 2018;470.https://doi.org/10.1186/s12889-018-5312-1.49. Harris-Fry H, Shrestha N, Costello A, Saville NM. Determinants of intra-household food allocation between adults in South Asia - a systematic review.Int J Equity Health. 2017;16:21. https://doi.org/10.1186/s12939-017-0603-1.50. Haviland WA. Cultural Anthropology, Belmont: California, Wadsworth/Thompson Learning; 2002.51. Hicks CC, Cohen PJ, Graham NAJ, Nash KL, Allison EH, D'Lima C, et al.Harnessing global fisheries to tackle micronutrient deficiencies. Nature.2019;574:95–8. https://doi.org/10.1038/s41586-019-1592-6.52. HLPE. Food losses and waste in the context of sustainable food systems: areport by the High Level Panel of Experts on Food Security and Nutrition ofthe Committee on World Food Security. Rome: Commitee on World FoodSecurity; 2014a. p. 117.53. HLPE. Sustainable fisheries and aquaculture for food security and nutrition:A report by the High Level Panel of Experts on Food Security and Nutritionof the Committee on World Food Security. Rome: Commitee on WorldFood Security; 2014b.54. HLPE. Nutrition and food systems: a report by the High Level Panel ofExperts on Food Security and Nutrition of the Committee on World FoodSecurity. Rome: Commitee on World Food Security; 2017. p. 152.55. UN Human Rights Council, Report submitted by the Special Rapporteur onthe Right to Food: Women's rights and the right to food, 24 December2012, A/HRC/22/50.56. Ickowitz A, Rowland D, Powell B, Salim MA, Sunderland T. Forests, trees, andmicronutrient-rich food consumption in Indonesia. PLoS One. 2016;11(5).https://doi.org/10.1371/journal.pone.0154139.57. Jones HA, Charlton KE. A cross-sectional analysis of the cost andaffordability of achieving recommended intakes on non-starchy fruits andvegetables in the capital of Vanuatu. BMC Public Health. 2015;15:10. https://doi.org/10.1186/s12889-015-1644-2.58. Kawarazuka N, Bene C. Linking small-scale fisheries and aquaculture tohousehold nutrition security: an overview. Food Security. 2010;2:343–57.59. Krefting L. Rigor in qualitative research: the assessment of trustworthiness.Am J Occup Ther. 1991;45(3):214–22.60. Lane D, Clarke CM, Forbes DL, Watson P. The gathering storm: managingadaptation to environmental change in coastal communities and small islands.Sustain Sci. 2013;8:469–89. https://doi.org/10.1007/s11625-013-0213-9.61. Leroy JL, Ruel MT, Frongillo EA, Harris J, Ballard T. Measuring the foodaccess dimension of food security: a critical review and mapping ofindicators. Food Nutr Bull. 2015;36(2):167–95.62. Lo M, Reed J, Costello L, Steel EA, Frimpong EA, Ickowitz A. The influence offorests of freshwater fish in the tropics: a systematic review. BioScience.2020;70(5):404–14. https://doi.org/10.1093/biosci/biaa021.63. Loring PA, Fazzino DV II, Agapito M, Chuenpagdee R, Gannon G, Isaacs M.Fish and food security in small-scale fisheries. In: Chuenpagdee R, Jentoft S,editors. Transdisciplinarity for small-scale fisheries governance: analysis andpractice, MARE Publication Series, vol. 21. Cham: Springer InternationalPublishing AG; 2019. p. 20.64. Madanijah S, Briawan D, Rimbawan R, Zulaikhah Z, Nandarwaulan N,Nuraida L, et al. Nutritional status of pre-pregnant and pregnant womenresiding in Bogor district, Indonesia: a cross-sectional dietary and nutrientintake study. Br J Nutr. 2016;116(S1):S57–66. https://doi.org/10.1017/S000711451600057X.65. Maxwell DG. Measuring food insecurity: the frequency and severity of“coping strategies”. Food Policy. 1996;21(3):291–303.66. Maxwell DG, Watkins B, Wheeler R, Collins G. The coping strategies index:field methods manual. Nairobi: CARE and the World Food Programme;2003.67. McGoodwin JR. Understanding the cultures of fishing communities: a key tofisheries management and food security. FAO Fisheries Technical Paper 401.Rome: FAO; 2001.68. McIntyre PB, Reidy Liermann CA, Revenga C. Linking freshwater fisherymanagement to global food security and biodiversity conservation. PNAS.2016;113(45):6. https://doi.org/10.1073/pnas.1521540113.69. Michaelsen KF, Hoppe C, Roos N, Kaestel P, Stougaard M, Lauritzen L, et al.Choice of foods and ingredients for moderately malnourished children 6months to 5 years of age. Food Nutr Bull. 2009;30(3):S343–404.70. Miller DD, Welch RM. Food system strategies for preventing micronutrientmalnutrition. Food Policy. 2013;42:115–28. https://doi.org/10.1016/j.foodpol.2013.06.008.71. Mills DJ, Tilley A, Pereira M, Hellebrandt D, Pereira Fernandes A, Cohen PJ.Livelihood diversity and dynamism in Timor-Leste: insights for coastalresource governance and livelihood development. Mar Policy. 2017;82:206–15. https://doi.org/10.1016/j.marpol.2017.04.021.72. Mills DJ, Westlund L, de Graaf G, Kura Y, Willman R, Kelleher K. Under-reported and undervalued: small-scale fisheries in the developing world. In:Pomeroy RS, Andrew NL, editors. Small-scale fisheries management: UnitedKingdom, CAB International; 2011. p. 1–15.73. Minarro S, Forero GN, Reuter H, van Putten IE. The role of patron-clientrelationships on the fishing behaviour of artisanal fishermen in theSpermonde Archipelago (Indonesia). Mar Policy. 2016;69:73–83. https://doi.org/10.1016/j.marpol.2016.04.006.74. Minister of Marine Affairs and Fisheries (2017). Estimation of Potential FishResources in Fisheries Management Areas, Number 50/KEPMEN-KP/2017.75. Ministry of Health. Guidelines for balanced nutrition. Jakarta: Government ofIndonesia; 2014.76. Monteiro CA, Cannon G, Levy RB, Moubarac JC, Louzada MLC, Rauber F,et al. Ultra-processed foods: what are they and how to identify them. PublicHealth Nutr. 2018;22(5):936–41. https://doi.org/10.1017/S1368980018003762.77. Mozzaffarian D. Dietary and policy priorities for cardiovascular disease,diabetes, and obesity: a comprehensive review. Circulation. 2016;133:187–225. https://doi.org/10.1161/CIRCULATIONAHA.115.018585.78. Muthayya S, Rah JH, Sugimoto JD, Roos FF, Kraemer K, Black RE. The globalhidden hunger indices and maps: an advocacy tool for action. PLoS One.2013;8(6):12. https://doi.org/10.1371/journal.pone.0067860.79. Nordhagen A, Rizwan AAM, Aakre I, Reksten AM, Pincus LM, Bokevoll A,et al. Nutrient composition of demersal, pelagic, and mesopelagic fishspecies sampled off the coast of Bangladesh and their potentialcontribution to food and nutrition security - the EAF-Nansen Programme.Foods. 2020;9:19. https://doi.org/10.3390/foods9060730.80. Pollnac RB, Crawford BR. Assessing behavioural aspects of coastal resourceuse. In: Proyek Pesisir Publications Special Report. Rhode Island: University ofRhode Island; 2000. p. 139.81. Pope C, Ziebland S, Mays N. Analysing qualitative data. Br Med J. 2000;320(7227):114–6. https://doi.org/10.1136/bmj.320.7227.114.82. Purnomo M. Ratio analysis of population to food needs in West ManggaraiRegency (Analisis ratio jumlah penduduk terhadap kebutuhan panganKabupaten Manggarai Barat); 2017. p. 71.83. Reksten AM, Somasundaram T, Kjellevold M, Nordhagen A, Bokevoll A,Pincus LM, et al. Nutrient composition of 19 fish species from Sri Lanka andpotential contribution to food and nutrition security. J Food Compos Anal.2020;91:13. https://doi.org/10.1016/j.jfca.2020.103508.84. Roos N, Leth T, Jakobsen J, Thilsted SH. High vitamin a content in somesmall indigenous fish species in Bangladesh: perspectives for food-basedstrategies to reduce vitamin a deficiency. Int J Food Sci Nutr. 2002;53(5):425–37. https://doi.org/10.1080/0963748021000044778.85. Roos N, Wahab A, Chamnan C, Thilsted ST. The role of fish in food-basedstrategies to combat vitamin a and mineral deficiencies in developingcountries. J Nutr. 2007;137:1106–9.86. Sandjaja S, Budiman B, Harahap H, Ernawati F, Soekatri M, Widodo Y, et al.Food consumption and nutritional and biochemical study of 0.5-12 year oldIndonesian children: the SEANUTS study. Br J Nutr. 2013;110:S11–20. https://doi.org/10.1017/S0007114513002109.87. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al.Saturation in qualitative research: exploring its conceptualization andoperationalization. Qual Quant. 2017;52:1893–907. https://doi.org/10.1007/s11135-017-0574-8.88. Schreinemachers P, Simmons EB, Wopereis MCS. Tapping the economicand nutritional power of vegetables. Glob Food Sec. 2018;16:36–45. https://doi.org/10.1016/j.gfs.2017.09.005.89. SEAMEO, Ministry of Health, & Wageningen University (2013). Foodcomposition table for Indonesia, SMILING.Gibson et al. BMC Public Health (2021) 21:355 Page 16 of 1790. Smith LC, Ramakrishnan U, Ndiaye A, Haddad L, Martorell R. Theimportance of women's status for child nutrition in developingcountries: IFPRI; 2003. p. 178.91. Thilsted SH, Thorne-Lyman A, Webb P, Bogard JR, Subasinghe R, PhillipsM, et al. Sustaining healthy diets: the role of capture fisheries andaquaculture for improving nutrition in the post-2015 era. Food Policy.2016;61:126–31.92. Tufford L, Newman P. Bracketing in qualitative research. Qual Soc Work.2012;11(1):80–96. https://doi.org/10.1177/1473325010368316.93. UNICEF. Strategy for improved nutrition of children and women indeveloping countries. New York: UNICEF; 1990.94. Vermeulen S, Wllesley L, Airey S, Singh S, Agustina R, Izwardy D, et al.Healthy diets from sustainable production: Indonesia. London: HoffmanCentre for Sustainable Resource Economy; 2019. p. 48.95. von Grebmer K, Bernstein J, Patterson F, Sonntag A, Klaus LM, Fahlbusch J,et al. 2018 global hunger index: force migration and hunger. Dublin &Bonn: Welthungerhilfe and Concern Worldwide; 2018.96. WFP. Food consumption analysis: calculation and use of the foodconsumption score in food security analysis. Rome: WFP; 2008. p. 24.97. WFP. Food Consumption Score Nutritional Quality Analysis Guidelines (FCS-N), Technical Guidance Note. Rome: Vulnerability and Assessment Mapping;2015. p. 26.98. WFP & BAPPENAS. The cost of diet study in Indonesia. Jakarta: WFP; 2017. p.69.99. White MT, Last PR, Dharmadi FR, Chodrijah U, Prisantoso BI, et al. MarketFishes of Indonesia, vol. 155, ACIAR monographs. Canberra: ACIAR; 2013.100. WHO (2014). What is hidden hunger? https://www.who.int/nutrition/topics/WHO_FAO_ICN2_videos_hiddenhunger/en/.101. WHO (2018). Healthy diet. http://www.who.int/mediacentre/factsheets/fs394/en/.102. WHO (2019). NLiS Country Profile: Indonesia.103. Wiesmann D, Bassett L, Benson T, Hoddinott J. Validation of the world foodProgramme's food consumption score and alternative indicators ofhousehold food security, IFPRI Discussion Paper (no. 00870). Washington D.C.; 2009.104. Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al.Food in the Anthropocene: the EAT-Lancet Commission on healthy dietsfrom sustainable food systems. Lancet. 2019;393:447–92. https://doi.org/10.1016/S0140-6736(18)31788-4.105. World Bank. World development indicators: Development Research Group;2020; http://data.worldbank.org/data-catalog/world-development-indicators.Accessed 31 Dec 2020.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Gibson et al. BMC Public Health (2021) 21:355 Page 17 of 17
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Coping or adapting? Experiences of food and nutrition insecurity in specialised fishing households in Komodo District, eastern Indonesia
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