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 , Western - 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.

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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.

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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, and 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). In each of the above-mentioned three VDCs approximately 40 households from each of the Dalit and Brahmin castes will be chosen.

Eligibility Criteria:

Inclusion criteria: Each household with Dalit and Brahmin women aged 18-44 years with at least one child under the age of five, i.e. 6-59 months, will be included in the study if they consent to participate in the study. If a household consists of co-wives but one of the wives does not have children matching the eligibility criteria, then both wives will still be included in the study.

Exclusion criteria: Dalit and Brahmin women, who do not consent to participate, and all adult men and women of other castes regardless of other eligible criteria will be excluded from the study. Households with severely sick women and children will not be included in the study. Severely sick women are operationalized as women who are unable to stand up; and for children, severely sick is regarded as inability to stand up and/or are disabled developmentally.

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Data collection procedures and parts of the study:

Part I: The following measures comprise the first part of the study and will be completed over the initial 9 weeks of the study period (Refer to Appendix A for proposed schedule)

Identifying eligible households. In each of the VDCs the local assistant and I will choose a landmark, for example a temple; and by taking it as a center point we will move around the center radially to compile a list of Dalit and Brahmin households, following the above-mentioned eligibility criteria, in all of the three VDCs. Households that satisfy the inclusion criteria will be tagged with a distinct numeral to expedite the identification of pre-selected households later. The compiled list will then be used as a sampling frame to randomly choose the sample size as described earlier (120 in each caste group).

Data collection. To collect data we will visit each selected household at the rate of 5 households per day. The format of the visit will be as follows: 10 minutes for obtaining consent form. 10 minutes for recording anthropometric measurements. 25 minutes for structured survey.

Consent forms and Anthropometric measurements. Consent forms will be developed following the Brown IRB examples and in consultation with Dr. McGarvey and Dr. Folmar during winter and spring 2011 in both English and Nepali. In every household, the consent form will be read and given to read to the participants at the beginning of the first visit. Considering the high rates of illiteracy (43.1%) among women in the region (Prasai et al., 2007) those who are illiterate and consent to the study will solely attest to it verbally and with their finger prints. But, those who are literate will provide a written consent. After the consent has been obtained, a standard anthropometric assessment following the WHO Child Growth Standards (WHO, 2006) will be performed with children under five. These measures include: height, weight and upper arm circumference. Anthropometric rods and weighing scale will be used for women to obtain height and weight respectively.

Structured survey. For the same concern about illiteracy described earlier, the survey questionnaires will be read verbatim to all of the study participants. The precise responses will then be recorded by the survey administrator, either the trained research assistant or me. The survey will be developed in consultation with Dr. McGarvey and Dr. Folmar during the winter and spring of 2011 and will include the following components:

• Household census questionnaires: This component of the survey will mainly aid in classification of the participants by age, households, caste, size and members of the households to name a few. The questionnaires, adapted from Dr. Folmar’s prior work (Appendix B), will facilitate data analysis and interpretation. • Socio-economic status (SES) questionnaires: Most of the SES data in the aforementioned VDCs have already been collected by Dr. Folmar and is currently in the process of being analyzed. So, the households that are missing SES information will be collected using the same questionnaires used by Dr. Folmar (Appendix C). • Food insecurity questionnaires: This component of the survey will assess the prevalence of food insecure households (mild, moderate and extreme). Thereby, allowing us to answer whether Dalit households are more food insecure than the Brahmin households. Household Food Insecurity Access Scale (HFIAS) for measurement of food access developed for use in cross-cultural context will be adapted in Nepali as per the guidelines given by the

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developers (Coates, J. et.al. 2007). Please refer to Appendix D for the unadapted version of questionnaires. The HFIAS will be adapted in Nepali during the spring of 2011 with the help of other Nepalese graduate students at Brown, who are fluent in the language. Before administering the survey in the study population, it will first be checked for face validity among a few households not eligible for the study. Thus, any necessary adjustments can be made to the questionnaires before administering it on the study population. Face validity measures will be followed as per the guidelines of the HFIAS developers.

Part II: In-depth interviews will be done over the remaining last week of the study period. (Refer to Appendix A for proposed schedule).

In-depth interviews. The main topics addressed in the in-depth interviews would be pertinent to childcare, perception of social status, caste status and its impact on availability, access and utilization of food. An example of agenda for the in-depth interview can be found in Appendix E. All formal interviews will be conducted by ensuring confidentiality of the participant and will be recorded using a tape recorder.

D. Data Analysis and Plan for dissemination The data will be analyzed upon return to the Brown University. Dr. McGarvey has expertise in analyzing anthropometric data. So under his guidance, I will compare the nutritional status of Dalits and Brahmins stratified by age, gender and socioeconomic status. HFIAS questionnaires will be analyzed using SPSS as per the guide given by the HFIAS inventors. The in-depth interviews will be transcribed and analyzed using Nvivo and in consultation with Dr. Folmar. I will analyze responses by first reading them for broad themes about food sufficiency and the factors related to food sufficiency. Then I will code data that indicates the specific ways that social status factors are associated with food sufficiency. In addition, I will take the qualitative methods in health research course taught by Dean Wetle in spring 2011 which will increase my skills in qualitative analysis, facilitating data analysis during fall 2011. The same data will be used to write my Master’s thesis during spring 2012. And, I also intend to draft a paper for publication based on data collected from this project.

E. Detailed Budget Estimated Items Cost Airfare $ 2,000 Application processing fee to NHRC, $100 The ethical review board in Nepal Room and board $1,200 Weekly transportation $200 Local assistant and Research assistant $1,200 Estimated Total $4,700

F. Relevant Coursework Fall of 2010 Spring of 2011 PHP 1070 Burden of Disease in Developing PHP2040 Applied Research Methods Countries PHP 2120 Intro to Epidemiology PHP2060 Qualitative Methods in Health Research PHP 2510 Principles of Biostatistics and Data PHP2070 MPH Analytic Internship Analysis

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