Nutritional status and social influences in Dalit and Brahmin women and children in Lamjung using mixed methods A. Objective and Specific Aims Objective: - To measure nutritional status, of women (18-44 years) and children under five (6-59 months), of Dalit and Brahmins by taking anthropometric measures in Lamjung district, Western Nepal - To conduct structured surveys and qualitative assessments of how underlying social and behavioral factors, e.g. availability, access and utilization of food, and childcare, influence nutritional status of Dalit and Brahmin women and their children Specific Aims: - To obtain the anthropometric measurements of height, weight and upper arm circumference to determine indicators of nutritional status including underweight, stunting and wasting among children under five; and to determine body mass index (BMI) among their mothers and stepmothers (if living in a same household) - To administer structured surveys to obtain household and socio-demographic information such as number of offspring and co-wives, caste status (Dalits or Brahmins), age of women and children, socio-economic status (SES) and food insecurity information - To conduct in-depth interviews of a subsample of Dalit and Brahmin women to understand how socio-cultural aspects in their lives affect food insecurity B. Background and significance It can be hypothesized that in Nepal, the social status of Dalit women– a collection of the untouchable castes – could contribute to having a lower nutritional status of themselves and their children, compared to maternal and child malnutrition among Brahmin castes (the highest ranked caste) residing in the same villages. This association between social status and malnutrition has been consistently found in developing nations (Gurung, 2010). But also in the US there is notable disparity in infant mortality rates between African Americans and whites throughout the decades 1960- 2000, with higher death rates in African Americans. Overall, the infant mortality rate during those decades improved for both the blacks and whites, but the gap in infant mortality rate in fact, widened from 1960 to 2000 between these two groups (Satcher et al., 2005). Despite adjusting for contemporaneous socioeconomic factors, infant mortality rate for African Americans were significantly higher than that of the whites (Satcher et al., 2005), which signifies the role of racial disparities in health inequality (Satcher et al., 2005 and Williams et al., 2005). Therefore, the longstanding racial discrimination in the US and its effect on the gap in infant mortality rate provides a rationale for studies of caste differences in western Nepal that may influence a hypothesized nutritional gap between the children of Dalit and Brahmin women. 1 The effect of social status on Dalit women is not merely a matter of low economic status. Dalits are positioned at the bottom of caste hierarchy (Goyal, R., Dhawan, P. and Narula, S., 2005) and were designated “untouchable” by Rana rulers in the Legal Code (Muluki Ain) of 1854 (Folmar, 2007). Since then, constructed notions of impurity have been directly associated with Dalits (Bennett, 2005 and Folmar, personal communication) and with this identity, they are often victims of an array of human rights violations including segregation, lack of access to food, water and land, and unequal employment opportunities (Goyal, R., Dhawan, P. and Narula, S., 2005). Not surprisingly, Dalits represent 80 percent of the total poor in Nepal (Goyal, R., Dhawan, P. and Narula, S., 2005) and 40 percent of Dalits are living below the national poverty line (Bennett, 2005). These staggering figures are also consistent with a suggestion that Dalits are significantly more malnourished than the rest of the population (Goyal, R., Dhawan, P. and Narula, S., 2005) Social status of Dalit women within the household also has the potential to bear upon nutritional status of their children. According to Stone (1978), the cultural role of women in Nepal is strictly that of a “child bearer”. Reproductive status of women is of primary significance in securing a well established position in a society. The more children a woman is able to reproduce the better are the prospects of a woman having a satisfying social life. In other words, inability to conceive after the first child is born can result in or frequently results in stigmatization. These women are considered inauspicious and, in some cases, are avoided because of their negative aura. Additionally, sons are preferred over daughters for various economic, social and religious reasons. Inability to have sons relegates a family to a position of worthlessness in society, and women have to bear the brunt of dealing with the consequences while men can, in general, compensate for such condescension. Women are blamed for the inability to reproduce sons and men are encouraged to remarry, which leads to cohabitation of two or more women in the same household. Moreover, girls get married during their early teens in most of the rural parts of the country and early childbearing yields a secure social status (Stone, 1978). It can then be implied that women of same age have varying social status depending upon whether they bear any offspring or not. Understanding the impact of social status of women on their own and their children’s nutritional status provide needed insight into why only minimal reduction in malnutrition in Nepal has been achieved in the past decade (Pradhan et al., 1997 and Prasai et al., 2007). In 1996, the percentages of stunted and underweight children (0-5 years) were 57% and 52% respectively. And in 2006, these percentages for stunting and underweight children declined only marginally, to 52% and 45% respectively (Pradhan, A., Aryal, R.H., Regmi, G., Ban, B. and Govindasamy, P., 1997; Prasai, Y. and Aryal, R.H., 2007). Although it has been predicted that the number of underweight and stunted children in Nepal will be lower in 2015 than in 2005, Nepal is still not on track for Millennium Development Goal (MDG) and stunting is also not predicted to be less than 40% by 2015 (Save the Children, 2009). In addition, there was a slight increase in the level of wasting (low weight for height) of children from 2001 to 2006 (UNDP, 2005). This finding suggests that with such minimal progress or increase in wasting, moving towards MDG in some cases could reverse course. Discrimination against Dalits could be a potential factor in preventing significant malnutrition reduction in Nepal. Most of the nutrition studies done in Nepal have focused on broader ecological zones and on overall differences in administrative regions of the nation. To my knowledge, no specific studies have been done to look at the dynamics of nutritional status of Dalits in comparison to their upper caste counterparts in Nepal. Although there have been few studies conducted in India along similar lines: they have either solely examined the nutritional status of Dalit women (Schmid et al., 2006) or have broadly estimated the nutritional status of Dalits compared to non-Dalits (Venkatesan, 2004). Thus, systematic study of the role of discriminatory behaviors in nutritional status of the Dalits and Brahmins may provide invaluable insights into the perpetuation of malnutrition in Nepal. 2 C. Methods Overview and Study Setting: This observational study will recruit 240 households using quota sampling and utilize mixed methods to compare the nutritional status of Dalit women and children to that of Brahmin women and children residing in the same communities. The study will be conducted in Lamjung district, which is situated in Western Nepal. In the district, three Village Development Committees (VDCs) namely Besisahar, Sundarbazar and Tarkughat are chosen for the study. The first part of the study will be visiting each eligible household (described later) and taking the following measures among women in those households (eligibility criteria described later): obtaining consent/assent, recording anthropometric measurements and administering structured survey. The second part of the study will include in-depth interviews that will be conducted among the selective households that are chosen based upon the responses to structured survey. Approximately 6 -12 households representing various mixtures of social and demographic characteristics (for example: households with co-wives, only sons, no sons etc.) in each of the caste groups from the three aforementioned communities will be chosen for in-depth interviews. In-depth interviews will provide complementary information to the structured survey and additional information on food insecurity. I will collect data with the help of an assistant by visiting all the eligible households. The local assistant will be hired in consultation with Dr. Folmar, who has done extensive research focusing on issues of identity and social justice for the Dalits of Nepal, including in Lamjung, for the past decade. As a citizen of Nepal brought up in the Nepalese culture I am fluent in the native language. Thus, I will be able to perform the fieldwork and observe the livelihoods and neighborhoods directly. I will be able to proceed with much deeper understanding and make more practical and efficient decisions while in the field. I also will not need a translator for interviews. My work in Lamjung will also benefit from my prior volunteer experience under supervision of Dr. Folmar in Jharuwarasi, Nepal in 2007: conducting ethnographic interviews among Dalit communities. Sample Size: Prevalence of stunting among children under five in Western Nepal is estimated at 50.4% (Prasai et al., 2007). However, there are no estimates of the prevalence of stunting among Dalits and Brahmins in Nepal. Hence, based upon the regional prevalence of 50.4% and the direction of hypothesis for the study, the expected prevalence of stunting among Dalits and Brahmins are estimated at 60% and 40% respectively. By taking into consideration the estimated prevalence of stunting among Dalits and Brahmins, and with a power of 0.85 and alpha of 0.05 for a two-tailed test, the sample size for each caste group is set at 120 (Fleiss, 2003; table A.3).