Report on Measuring change in nutritional status and coping strategies in response to monga of the Chars

Transcription

1 Report on Measuring change in nutritional status and coping strategies in response to monga of the Chars Livelihoods Programme (CLP) cash-for-work intervention Prepared by Helen Keller International, Bangladesh for Chars Livelihoods Programme (CLP)

2 Abbreviations ARI ARU BMI CED CFW CI CLP DMU FOU HKI IMO NCHS NGO SD SIC SPSS Acute Respiratory Tract Infection Analysis and Reporting Unit Body Mass Index Chronic Energy Deficiency Cash For Work Confidence Interval Chars Livelihoods Programme Data Management Unit Field Operation Unit Helen Keller International Implementing Organization National Centre for Health Statistic Non-Government Organization Standard Deviation Scheme Implementation Committee Statistical Package for Social Science 1

3 Table of Contents Executive Summary Introduction Methods Study design Nutritional indicators Sample size Sampling Training and quality control Data collection Data entry and cleaning Data analysis Results and Discussion Basic characteristics of households at baseline Changes in nutritional status Food consumption patterns and food availability Crisis and coping mechanisms Conclusions Recommendations...22 Appendix 1: Household Selection Procedures Appendix 2: Study Questionnaire

4 List of Tables Table 1. Table 2. Table 3. Socio-demographic characteristics of CFW-participant and non-participant households at baseline. Nutritional status of women in CFW-participant and non-participant households at baseline and endline Nutritional status of children aged 0-59 months in CFW-participant and nonparticipant households at baseline and endline List of Figures Figure 1a. Changes in nutritional status among children aged 0-23 months in CFW participant and non-participant households at baseline and endline Figure 1b. Changes in nutritional status among children aged months in CFWparticipant and non-participant households at baseline and endline Figure 2. Proportion of malnourished children aged 0-59 months by participation in CFW programme households and in non-participant households Figure 3 Figure 4. Figure 5. Proportion of households who ate fewer and smaller meals in the CFW-participant and non-participant households at baseline and endline. Per capita consumption of rice per week in the CFW-participant and non-participant households at baseline and endline Proportion of households who had non-rice cereals in CFW-participant and nonparticipant households at baseline and endline. Figure 6. Proportion of women in the CFW-participant and non-participant households who had consumed animal source foods in the 7 days before the interview at baseline and endline Figure 7. Proportion of mothers and children aged 6-59 months in the CFW-participant and non-participant households who had consumed a diverse diet in the last 7 days before the interview at baseline and endline Figure 8. Proportion of CFW-participant and non-participant households who faced monga in the last one month at baseline and endline Figure 9. Proportion of CFW-participant and non-participant households who took a food loan in the last one month at baseline and endline Figure 10. Coping strategies used by CFW-participant and non-participant households in response to monga Figure 11. Proportion of CFW-participant and non-participant households where some members migrated to cope with monga at baseline and endline 3

5 Executive Summary Monga is a Bangla term which reflects acute food deprivation and is often experienced in the northern region of Bangladesh. During 2006 monga the Chars Livelihoods Programme (CLP) introduced some labour intensive cash-for-work (CFW) interventions in Gaibandha and Kurigram to enable households to increase their purchasing power to meet their daily food requirements. CLP provided households with a minimum of 25 and a maximum of 30 days of employment which involved earthwork activities through the CFW intervention. Until now, no study has demonstrated the influence of monga on nutritional status or has shown the impact of any intervention on the health and nutritional status of a monga affected population. Given the paucity of research evidence, Helen Keller International (HKI) conducted research in CFW-participant households to measure change in nutritional status, food consumption patterns and households coping strategies to mitigate the effect of monga. Baseline and endline data collected respectively during September/October and November/December 2006 showed no significant change in nutritional status with respect to Body Mass Index (BMI) in women and men and stunting and underweight amongst children under age five years. However, findings have provided conclusive evidence that the CFW intervention was an effective measure to minimize and negate the negative consequences for monga on affected households with positive outcomes on dietary patterns, coping strategies and on family member migration. Despite the insignificant changes in nutritional status over the survey period, at endline a significant improvement in dietary pattern was evident amongst CFW-participant households compared to baseline. Data showed a reduction in the proportion of CFW-participant households who reported to have consumed fewer number of meals (80.6% vs. 19.7%, P<0.001); and the proportion of households who reported to have consumed smaller quantity of food at meals (63.0% to 10.5%, P<0.001). The proportion of non-participant households showed no significant changes in these two indicators, indicating that CFW activities helped the participant households to negate the negative effects of monga. Similarly, at endline, significantly more women in CFW-participant households had consumed animal source foods and the proportion of both women and children who had consumed a diverse diet, i.e. consumed three or more variety of foods for more than three days in the last 7 days, increased from baseline to endline (women: 7.5% to 12.9%, P<0.001; children: 5.5% to 13.2%, P<0.001). Conversely, the non-participant households showed a decline in both the proportion of women consuming animal foods; and the proportion for both women and children who consumed diverse diet. At baseline an equally large proportion of CFW-participant and non-participant households (89.8% vs. 99.5%) reported to have experienced monga. However, the proportion of CFWparticipant households who had reported to experience monga in the previous month declined significantly at endline to 24.5%, while an equally large proportion of the non-participant households experienced monga at both survey periods. In terms of coping strategies, taking of a food loan in the previous month declined sharply (56.3% to 17.8%) among CFW-participant households, but increased among non-participant households (70.7% to 75.5%). Also at endline, a significantly higher proportion of non-participating households reported migration of a family member, which was more than three times higher than that of the CFW-participant households. These findings indicate that the CFW intervention was effective in negating the 4

6 negative consequences of monga besides the economic benefit to participating households as preventing family migration also has a positive impact on family stability and social cohesion. While there were no significant changes in nutritional status in the CFW-participant and nonparticipant groups over the survey period, there were some indications of change within the CFW-participant households. At endline a significantly higher proportion of women who actively participated in the CFW intervention were moderately or severely thin (BMI<17.0 kg/m 2 ) than women who had not worked in the CFW (29.5% vs. 22.3%, P<0.024). However the assumption is that the two cohorts of women were identical before cash for work began. It should be noted that at baseline the proportion of women who were malnourished (BMI<18.5 kg/m 2 ) were similar for CFW-participant (52.2%) and non-participant (55.4%) households. However, further exploration is needed to confirm this assumption of similar cohorts. Nonetheless, the possibility of deteriorating BMI in women actively employed in CFW must not be ignored and provides an opportune moment to call for increased gender sensitivity in all future CFW interventions. Among children, prevalence of stunting and underweight remained unchanged in both CFWparticipant and non-participant households over the survey period. However, at endline the prevalence of wasting among children aged 0-59 months declined significantly for both CFWparticipants (9.7% vs 13.5%, P<0.01), and non-participants (19.9 vs 11.2%, P<0.001). The decline in wasting (acute malnutrition) among children in both groups of households may be due to seasonality, as a similar pattern was seen in national level data HKI/NSP findings from 2005 data (11.0% in Oct-Nov, 6.7% in Dec-Jan). Among CFW-participant households the proportion of stunted (50.0%) and underweight (62.9%) children aged 0-59 months were higher in households where women worked for the CFW intervention, compared to children in households where the male worked for CFW (40.5% and 50.9% respectively). Although these differences were not statistically significant, they do potentially indicate reduced levels of care practices of employed CFW-participant mothers, and more likely for those still breastfeeding their infants. This may also explain the apparent, greater decline in wasting at endline (acute malnutrition) amongst non-participant household children when compared to CFW-participant households. The research findings showed that at baseline a high proportion of households had already experienced monga in both groups and at endline there was no impact on nutritional status among the households who had improved access to social protection, in the form of the CFW intervention. This may be due to the short duration (25-30 days) of the intervention. The findings showed that amongst CFW-participant households a higher proportion of women who actively participated in the CFW intervention were severely malnourished compared to those women where someone else had participated in the CFW intervention. This questions the high energy demands of the hard physical labour of the CFW intervention. The findings have provided conclusive evidence that despite not having any impact on the nutritional status of both adults and children the CFW intervention was an effective measure to minimize and negate the negative consequences of monga on affected households which included improved dietary patterns, improved coping and prevention of family member migration. 5

7 1. Introduction Monga or Akal a cyclic phenomenon of poverty and hunger are the local terms used to indicate acute deprivation of food 1. This condition occurs almost every year mostly in some north-western districts of Bangladesh, when households experience severe lack of access to food, particularly after the planting and before the Aman harvest season over the months of mid-september to mid-november (Bengali month Ashwin to Kartik 2 ). Monga is characterized by diminished purchasing power during a specific period of time. A combination of factors such as the seasonal scarcity of employment leading to reduced household income, coupled with seasonal price hikes of basic food commodities all result in a lack of access to food; especially amongst rural poor landless families 3. Furthermore, topography and climate make the monga-affected area ecologically vulnerable to destabilizing elements including floods, river erosion, drought and cold spells. In this part of Bangladesh natural disasters occur more frequently and with more intensity than in other regions of Bangladesh, affecting the landless, the poor, and even the land-owners, all of whom survive mainly on agriculture or agricultural wage labour. In the context of vulnerability, seasonal food insecurity manifests itself in all three dimensions of food availability, access, and utilization 4. Monga-affected households coping mechanisms are well documented and include labour pledged in advance and/or temporary migration of male members, in search of work opportunities, often leaving women and children more vulnerable and unable to meet their basic needs. During these periods of scarcity families are forced to take alternative foods of perceived inferior quality, skip meals and/or reduce meal size. Both the phenomenon and the coping strategies are risks for increasing malnutrition 4. The Chars Livelihoods Programme (CLP), an initiative of national and international organizations, offered short and long term livelihoods schemes to the monga affected areas. As a short term measure CLP introduced some labour intensive cash-for-work (CFW) interventions to enable households to increase their purchasing power to meet daily food requirements. Beneficiary workers were eligible considering their level of income and perceived level of financial insecurity as determined by their fellow villagers. Disabled and physically challenged persons were eligible to participate through the nomination of a physically fit person to work in their place. During the 2006 monga period eligible beneficiaries were entitled to have a minimum of 25 and a maximum of 30 days of employment that involved earthwork activities. Based on CFW phase-wise implementation strategy beneficiary households did not enter and exit the programme simultaneously. 1 Bhattacharya D. State of the Bangladesh economy in the fiscal year Second Interim Report (July 03-April 04). Available at: Accessed on 24 Jan Local Consultative Group (LCG), Bangladesh. Report from the special DER meeting on 'Monga' Source: Available at Accessed on 24 Jan, Hossain M. Containing monga in northern districts. The Daily Star. Vo.l 5 Num 179. Wed, 24November, Available at: Accessed on Dec 26, Report on Monga in Northern Bangladesh. Overview. Available at. on 26 Dec,

8 Until now, no study has demonstrated the influence of monga on nutritional status; or has documented the impact of any intervention programme on the health and nutrition status of a monga affected population. Given the paucity of research evidence, CLP approached Helen Keller International (HKI) to undertake a study to explore whether the CFW intervention mitigates the consequences of monga or prevents deterioration in nutritional status. Aim & Objectives The aim of the study was to explore whether improved access to social protection, in the form of the cash-for- work scheme, to households who experience monga has an impact on nutritional status. The objectives of the study were: To measure the impact of monga on nutritional status of household members To explore the impact of monga on food consumption patterns of household members To explore whether the cash-for-work scheme to households who experience monga prevents (or delays) malnutrition among these households 2. Methods 2.1 Study design A quantitative longitudinal survey was conducted in Gaibandha and Kurigram two northwestern districts of Bangladesh. Baseline and endline data were respectively collected during September/October and November/December Data were collected from an adult male and female and one index child aged 0-59 months from CFW-participant and nonparticipant households. For females, preference was given to the mother of the child under age five years. Besides data on the mother of the child, data were also collected from the person who was employed in the CFW intervention. At endline, the same households and population were re-interviewed. 2.2 Nutritional indicators Indicators of nutritional status that were used to assess programme changes are defined as below: Stunting: Stunted children have low height or length-for-age, an indication of longterm under nutrition (calculated as children with Height-for-Age Z Score < 2 standard deviations [SD] using NCHS reference) Underweight: Underweight children have low weight for age, and indicates a mix of acute and chronic malnutrition (calculated as children with Weight-for-Age Z Score < 2 SD using NCHS reference) Wasting: Wasted children are those who have low weight for height, an indication of recent, acute malnutrition (calculated as children with Weight-for-Height Z Score < 2 SD using NCHS reference) Body Mass Index (BMI) is calculated for adult men and non-pregnant women using the formula weight [kg]/height [m 2 ]. An adult with a BMI <18.5 kg/ m 2 is defined as having low BMI, i.e., malnourished, and those with BMI <17.0 kg/ m 2 is considered as moderate to severely thin adults. 7

9 2.3 Sample size A longitudinal study was designed to measure change in nutritional status and coping strategies in CFW participating households. Sample size was estimated using the formula: n Sample size was calculated based on hypothetical changes in different parameters: Parameters 2 { z [ 2 p( 1 p) )] + z [ p (1 p ) + p (1 p )]} ( p ) 2 = d 1 α / 2 1 β / * p Proportion of households at baseline (November) Difference in proportions of CFWparticipant and non-participant households at endline Nutritional status Coping strategy indicator indicator BMI <18.5 kg/m 2 Households taking a food loan 55% 15.0% 10% 7.5% Proportion of CFW-participant households 45.0% 7.5% after intervention Confidence level 95% 95% Power 80% 90% Design effect for cluster sampling (d) 2 2 Sample size required Dropout rate for longitudinal design 10% 10% Sample size per group Note: Estimates are based on prevalence among functionally landless households in Kaunia in northern Bangladesh in Oct-Nov round of data collection of Nutritional Surveillance Project in The sample size was calculated to test a nutritional indicator, the expected difference in chronic energy deficiency (CED: BMI <18.5kg/m 2 ) between mothers in CFW-participant and non-participant households at 95% confidence level, at 80% power with a design effect of 2 for multistage cluster sampling and accounting for a 10% drop-out rate, a sample size of 860 households per group (CFW-participants and non-participants) was determined. Given the short duration of the CFW intervention changes in nutritional status was not expected, therefore the coping strategy indicator households taking a food loan was used. Calculations using the coping strategy indicator households taking a food loan to test the difference in proportions of households taking a food loan (in the last month), at 95% confidence level, at 90% power with a design effect of 2 for multistage cluster sampling and accounting for a 10% drop out rate, a sample size of 815 households per group was determined. Adjusting for the number of households at different layers (union, village), and the practical ease of the sample layout the final sample size per group was set at 900. The 900 households per group was planned to include 30 households from two villages in a total of 15 unions. However, given the difficulty to collect 30 eligible households in some villages the data collection team was encouraged to collect at least 35 households in the villages were they could. At baseline, a total sample of 1050 CFW-participant households and 1019 non-participant households was collected

10 2.4 Sampling CFW-participant households were selected randomly from a list of households, villages and unions provided by CLP. Non-participant households were selected by HKI from nonintervention villages, based on the inclusion criteria: not participating in CFW or any other livelihoods programme and that the household was landless and asset-less as defined by CLP 5. To assure homogeneity between the two groups, non-participant households were selected from random lists of non-intervention villages within the same 15 unions, where CFW was implemented. For non-participant household selection, systematic sampling was followed to include every third household who met the non-participant household selection criteria provide by CLP. The sampling layout is shown as below: 15 unions Village 1 Village 2 30 households 30 households Details for household selection is described in Appendix 1. 5 HKI/CLP (21 September 2006). Contract agreement Landless: owing zero decimals of land; Asset-less: owing the equivalent of Tk. 5000/- or less, for example up to 2 goats and 6 chickens; and not knowingly participating in the CLP CFW scheme or any other income or asset provision programmes sponsored by the CLP or other international or national agencies or NGOs. 9

11 2.5 Training and quality control Data collection teams received a 4-day basic training before the baseline data collection and a 2-day refresher training before the endline data collection. Survey quality control teams revisited 5-6% of the households, who were previously interviewed by data collection teams to re-collect and check quality of data. 2.6 Data collection The baseline survey was conducted between 24 September and 12 October, 2006 and the endline survey was conducted between 13 November and 11 December, Data collection included anthropometry of an adult male and female from the household and one child under age five years. An interview with the female member of the household was conducted using a structured questionnaire. 1. Anthropometric measurement: Weight, Height, MUAC with Age; for children less than five years of age and weight and height for an adult male and female member of the household. 2. Structured questionnaire (Appendix 2) on basic underlying causes of malnutrition: Food consumption: 7day food recall of females and the index child Changes in dietary habits Morbidity (Diarrhoea, ARI and fever) of mothers and children Selected SES of the household head Household contingency plans and coping strategies for monga 2.7 Data entry and cleaning Data were entered and cleaned following standard procedures using a phased approach, as data were collected in the field, the raw data were sent back to HKI in Dhaka. Anthropometric data for women and children were converted to Z-scores based on NCHS reference using the software package Anthro Data analysis Data were analyzed to produce descriptive statistics, using Statistical Package for Social Science (SPSS, version 11.5, SPSS Inc. Chicago, IL), expressed as means, medians with standard deviations (SD), or percentages, with 95% confidence intervals (CI) where appropriate. To calculate the significance of the differences in the proportions of the examined indicators between the intervention and comparison groups, the chi-square test and the Mann- Whitney U-test was used for comparing non-parametric variables. Statistical significance was defined as P<

12 3. Results and Discussion 3.1 Basic characteristics of households at baseline Data collected at baseline (Table 1) showed that overall CFW-participant and non-participant households were similar in respect to number of household members, adult earners and closed latrine usage. However, CFW-participant households had higher socio-economic status as reflected by asset ownership compared to non-participant households. A higher proportion of households among CFW-participants reported to own homestead and/or cultivable land compared to non-participants (37.9% vs. 0.0%, P<0.001) 6. Also participation to NGO programmes other than CLP was higher among CFW-participating households than nonparticipant households. This finding of intervention mis-targeting is consistent with a study where similar participatory beneficiary selection processes were employed 7. Table 1. Socio-demographic characteristics of CFW-participant and non-participant households. CFW-participant (n =1050) Non-participant (n =1019) No. of household member (median) 5 4 No. of adult earner (median) 2 2 Closed latrine usage (%) Ownership of 1cow/ buffalo (%) 27.8* 0.2 Ownership of 2 Goat/sheep (%) 10.5* 1.2 Membership of NGO (%) 23.2* 5.1 Experiencing monga (%) *Difference between CFW-participant and non-participant were significant (P<0.05). 3.2 Changes in nutritional status Amongst CFW-participant households, at endline the study did not find any significant changes in nutritional status of women (Table 2) or children (Table 3). This was not unexpected given the short duration of the CFW intervention. Against the national reference for the respective nutritional indicators showed that at baseline both groups had significantly higher levels of underweight and wasting than the national level, this is expected given the vulnerability of the Chars. Also the majority of the households (89.8 and 99.5%) reported to be already affected experiencing monga. Table 2. Nutritional status of women in CFW-participant and non-participant households at baseline and endline Indicator CFW-participant Non-participant National Baseline Endline P-value Baseline Endline P-value Non-pregnant (n = 973) (n = 797) - (n = 931) (n = 824) - (n=58976) women (%) Malnourished (BMI<18.5 kg/m 2 ) (%) Moderate to severely malnourished (BMI<17.0 kg/m 2 ) CLP, Personal Communication with Lucy Scott. Landownership on the chars is complex and people say they own land not only if they hold title-deeds to the land, which is extremely rare, but also if other villagers allow them to live, uncontested, on khas land. 7 RDRS, Survey on Food Security and Hunger in Bangladesh 11

13 The proportion of adult non-pregnant women who were malnourished (BMI<18.5kg/m 2 ) showed no changes over the survey period for either CFW-participants (baseline 52.2% vs. endline 54.0%, P=0.465), or the non-participant group (baseline 55.4% vs. endline 55.0%, P=0.850). Among women who had chronic energy deficiency (BMI<18.5 kg/m 2 ) at baseline in both CFW-participant and non-participant households (data not shown) the median BMI remained unchanged at endline for both groups (CFW-participants: to kg/m 2, non-participants: to kg/m 2 ). To explore whether active involvement in the CFW program had any influence on these women s nutritional status further analysis of endline data among women within the CFW-participant households was done. Given that no intervention took place among women in non-participant households no change in nutritional status was expected. Further to this, given that at baseline no CFW activities had taken place only endline data for women from participating households was considered for further analyses. Within the CFW-participant households, endline data showed that a higher proportion of women (29.5% vs. 22.3%, P<0.024) (data not shown) who actively participated in the CFW program were moderate to severely thin (BMI <17.0 kg/m 2 ) than women from households where a male member had worked in the CFW intervention. This finding may suggest that women who were employed in CFW may have had higher energy expenditure from the physical labour of earthmoving and this might have offset any positive influence that CFW may have provided. But equally, it is plausible that those women who worked for CFW had no alternative but to work for the households in the absence of a male (son/husband) counterpart and these women may represent the poorest and thus potentially thinnest women in the CFW intervention. It should also be noted that the average BMI did not change significantly even among women with a normal nutritional status (BMI 18.5 kg/m 2 ) in CFW-participant households (median BMI at baseline and endline 20.02), and non-participant households (median BMI at baseline and endline 19.51). Amongst males the proportion of malnourished males (BMI <18.5kg/m 2 ) remained unchanged in both the CFW-participant households (baseline 58.3% vs endline 58.8%, P=0.862) and the non-participant households (baseline 60.7 % vs. endline 59.6%, P=0.710) (data not shown). Table 3 showed that from baseline to endline the prevalence of underweight and stunting among children aged 0-59 months remained unchanged among both CFW-participant and non-participant households. The proportion of children under five years of age with wasting declined significantly for both CFW-participants (baseline 19.7%; endline 13.5%, P<0.01), and non-participants (baseline 19.9; endline 11.2%, P<0.001). The decline in acute malnutrition among children (wasting) in both groups of households may be due to seasonality, as supported by other data sets, the HKI/Nutritional Surveillance Project data (11.0% in Oct-Nov, 6.7% in Dec-Jan) 8. 8 HKI/IPHN. Bangladesh in Facts and Figure: 2005 Annual Report of the Nutritional Surveillance Project. Dhaka: Bangladesh

14 Table 3. Nutritional status of children aged 0-59 months in CFW-participant and nonparticipant households at baseline and endline Indicator CFW-participant Non-participant National Baseline Endline P-value Baseline Endline P-value Children (0-59 mo) (n = 645) (n = 497) - (n = 873) (n = 758) - (n=74,606) Stunting (%) % Underweight (%) %, Wasting (%)** < %, 6.7% *According to nationally representative data of the Nutritional Surveillance Project 9 ** Against the Nation Prevalence of wasting among underfive children for the respective data collection periods was 13.5% in Aug-Sept and 11.0% in Oct-Nov. Even when disaggregated by age, the indicators of chronic malnutrition (stunting and underweight) did not show significant changes among children aged 0-59 months over the period for either CFW-participant nor non-participant households (Figure 1a and 1b). Although not significant, the prevalence of wasting fell marginally among children aged 0-23 months from participating households. The decline in the prevalence of wasting was larger and significant in non-participant households for the same age group (0-23 months); and remained similar for both CFW-participant and non-participant households among older children aged months. Figure 1 a. Changes in nutritional status among children aged 0-23 months in CFW-participant and non-participant households at baseline and endline Figure 1 b. Changes in nutritional status among children aged months in CFW-participant and non-participant households at baseline and endline Baseline Endline Baseline Endline Proportion (%) Underweight Stunting Wasting Proportion (%) Underweight Stunting Wasting CFWparticipant Nonparticipant CFWparticipant Nonparticipant CFWparticipant Nonparticipant CFWparticipant Nonparticipant CFWparticipant Nonparticipant CFWparticipant Nonparticipant While both CFW-participant and non-participant households experienced monga one possible explanation for the nutritional status to remain unchanged among children in CFW-participant households compared to non-participating households may have been constraints on mothers care. Some field teams reported that some of the CFW-participant mothers who were 9 HKI/IPHN. Bangladesh in Facts and Figure: 2005 Annual Report of the Nutritional Surveillance Project. Dhaka: Bangladesh

15 employed in the CFW-intervention reported not have had enough time to cook or take proper care of their children, an essential contributor to children s nutritional well-being. Figure 2. Proportion of malnourished children aged 0-59 months by participation in CFW programme households and in non-participant households 100 Non- participant CFW- active male participant CFW -participant (overall) CFW- active female participant Child stunting Child underweight Child wasting The proportion of stunted and underweight children, aged 0-59 months in CFW-participant households was higher in households where women worked in the CFW intervention compared to the prevalence among children in households where males had worked (stunting: women CFW-participating households 50.0%, non-participating households 40.5%; Underweight: women CFW-participating households 62.9%, non-participating households 50.9%). However, these differences were not significant (Figure 2). Neither were they significantly different from similar-aged children in control households. Figures 1a and 1b showed that in general the children from CFW-participant households displayed lower levels of stunting and underweight than children from non-participant households. However, when these two indicators and that for wasting are compared within participant households where the mother was employed in CFW activities, child nutritional status was marginally but not significantly worse than in those households where the male was employed (stunting: 50.0% vs. 40.5%; underweight: 62.9% vs. 50.9% and wasting 14.4% vs. 13.3%). These values where mothers were employed in CFW were not significantly different to the values obtained from non-participant households (stunting: 50.0% vs. 50.6%; underweight: 62.9% vs. 57.3% respectively). 3.3 Food consumption patterns and food availability At baseline and endline, households were asked about their perceptions regarding food consumption in terms of the number and size of meals consumed in the last seven days compared to the usual. In Figure 3, compared to baseline, there was a significant reduction in the proportion of CFW-participant households that reported to have had fewer number of meals at the endline (80.6% vs. 19.7%, P<0.001), while the proportion remained unchanged for the non-participant households (97.2% vs. 98.2%, P=0.131). The results showed a similar reduction in the proportion of participant households who reported to have had smaller quantities of food at meals (63.0% to 10.5%, P<0.001) however, the proportion of non- 14

16 participant households having smaller quantities of food at meals increased significantly at endline compared to baseline (74.1%-86.0%, P<0.001). These results indicate that CFW activities helped the participant families to negate the effects of monga by improving the number and amount of meals consumed. Figure 3. Proportion of households who ate fewer number of meals and smaller quantities of food at meals in the CLP/CFW-participant and non-participant households at baseline and endline. Baseline Endline Proportion (%) CFW- Participant Non-participant 10.5 CFW- Participant Non-participant Have fewer number of meals Have smaller quantity of food at meals Per capita rice consumption/week at endline increased among the CFW-participant households (2.6 to 3.2 kg) and declined in the non-participant group (2.2 to 1.8 kg), however these differences were not significantly different (Figure 4). But at endline the CFWparticipant households were consuming almost double (3.2 vs. 1.8 kg) the rice consumption/ week of the non-participant households. The endline findings indicate that CFW activities helped the participant households to increase the amount of rice consumed and negate the negative effects of monga as experienced by the decreased rice consumption amongst the nonparticipant households. 15

17 Figure 4. Per capita consumption of rice per week in the CFW-participant and non-participant households at baseline and endline. Error bars represent SD of mean. 5 Baseline Endline 4 Mean (kg) CFW-Participant Non-participant In Bangladesh, people eat rice as the staple cereal and only substitute with other cereals if they cannot afford rice, since alternative cereals are usually less expensive. These alternative cereals are less preferred and are perceived to have less nutritional value. A higher proportion of non-participating households (52.6%) ate non-rice cereals at baseline than CFWparticipants (42.2%). The findings that almost half of the households in both CFW-participant and non-participant households were consuming non-rice cereals at baseline further supports the report of households already experiencing monga. The proportion of households eating non-rice cereals significantly decreased among CFW-participant households and increased further for non-participant households (Figure 5). Figure 5. Proportion of households who had non-rice cereals in CFW-participant and non-participant households at baseline and endline. Baseline Endline 60 Proportion (%) CFW-Participant Non-participant In the context of increased rice consumption amongst CFW-participant households infers that CFW-participant households did not need to rely on non-preferred and perceived lower quality non-rice cereals. These two outcomes indicate that the CFW-participant households who equally experienced monga at baseline had improved access to purchase and revert to 16

18 usual and preferred rice cereal as a result of the household s participation in the CFW intervention. This also enabled these households to increase their amount of rice consumption as well. Data from both CFW-participant and non-participant households showed that women in all households were the most food deprived (women were highest among those who ate fewer meals) at both periods (data not shown). At baseline, a higher proportion of women in the CFW-participant households consumed animal source foods (fish, milk, egg, meat) compared to non-participant households. From baseline to endline, the proportion of women in CFWparticipant consuming animal-source foods (other than meat) had significantly increased (Figure 6). However, at endline the proportion of women who consumed animal foods (other than egg) on at least one day in the previous week of the survey had decreased amongst nonparticipant households compared to the baseline. Amongst non-participant households, the proportion of women who consumed fish in the previous week dropped significantly and consumption of other animal source foods remained unchanged; and among CFW-participant households the proportion of women consuming animal source foods had increased for most foods. These changes in consumption indicate that participation in the CFW intervention enabled households to increase overall consumption of energy and micronutrient-rich foods. These results further support the finding that CFW-participant households had increased the number of meals and amount of food at meals from baseline to endline. Figure 6. Proportion of women in the CFW-participant and non-participant households who had consumed animal source foods at least on one day in the 7 days before the interview at baseline and endline Baseline Endline Proportion (%) CFW- Participant Nonparticipant CFW- Participant Nonparticipant CFW- Participant Nonparticipant CFW- Participant Nonparticipant Fish Milk Egg Meat Food diversity defined as consuming three or more variety of foods on three or more days in the last 7 days prior to the interview shows in Figure 7 that at baseline, the proportion of CFW-participant households who consumed a diverse diet was double that of the nonparticipant households (7.6% vs 3.6%), further supporting the finding of socio-economic difference between the two groups. Despite more than double the proportion of CFWparticipant households who consumed a diverse diet compared to non-participant households the proportion of Chars households consuming a varied diet is exceptionally low; less than 10% of households consumed a diverse diet. For CFW-participant households, there is a 17

19 significant increase in the proportion of women and children aged 6-59 months who consumed a diverse diet from baseline to endline (women: 7.5% to 12.9%, P<0.001; children: 5.9% to 13.8%, P<0.001). Conversely, the proportion of women and children consuming a diverse diet decreased among the non-participant households during the same period (women: 3.6% to 0.7%, P<0.001; children: 3.4% to 0.6%, P<0.001). Figure 7. Proportion of mothers and children aged 6-59 months in the CFW-participant and non-participant households who had consumed a diverse diet (consuming 3 or more varieties of foods items on 3 or more days) in the previous 7 days at baseline and endline Proportion (%) CFW-participant Non-participant CFW-participant Non-participant Women Children aged 6-59 months 3.4. Crisis and coping mechanisms At baseline, an equally large proportion of CFW-participant and non-participant households (89.8% vs. 99.5%) reported to have experienced monga. However, for CFW-participant households the proportion declined significantly at endline (from 89.8% to 24.5%) contrary to non-participant households whose monga experience is reflected equally high at both survey periods (Figure 8), indicating that the CFW intervention was able to alleviate the affects of monga and CFW-participant households were able to appreciate this and experienced this as positive. 18

20 Figure 8. Proportion of CFW-participant and non-participant households who faced monga in the previous one month at baseline and endline 100 Baseline Endline 80 Proportion (%) CFW-Participant Non-participant Monga experience was reflected as scarcity of food (98%), and/or difficulty to find employment (88%), high price of food (60%); and most households (57.3%) considered Ashwin (mid September-mid October) as the monga period. Given that at baseline both these household groups had very high proportions of households who had taken a loan for food (56.5% vs 70.7%) underscores that these households were already experiencing monga. This baseline finding further supports the higher socio-economic status of the CFW-participant households compared to the non-participant households. Among the CFW-participant households the proportion of households who took a loan for food in the previous month of the survey decreased dramatically (56.3% to 17.8%), whereas it increased (70.7% to 75.5%) in the non-participant group (Figure 9). It can be deduced that the money received from CFW supported the participant households food needs therefore lowering the need to take a loan for this particular need. The findings showed that CFW activities mitigated the need to take a loan which for many households comes at a high price; an added financial burden with negative impacts long after the monga crisis. Figure 9. Proportion of CFW-participant and non-participant households who took a food loan in the last one month at baseline and endline Baseline Endline Proportion (%) CFW-Participant Non-participant 19

21 Taking an informal loan i.e. borrowing money from friends or relatives (not from a bank or specific institution) on a short-term basis, was the most common coping strategy among those who experienced monga at endline for both CFW-participants (73.5%) and non-participants (85.6%), with a higher proportion of money borrowing amongst non-participants (Figure 10). Also more of the non-participant households reported taking a loan, using saving, or selling/mortgaging valuables (jewelry, utensils); all common practices and strategies to alleviate the lack of financial resources. Figure 10. Coping strategies used by CFW-participant and non-participant households in response to monga Proportion (%) Loan (in-formal) Sell, mortage Temporary migration Loan (Formal) Sale advance labor Use of saving Microcredit CFW-Participant Non-participant At baseline an equal proportion of households from both groups had reported family member migration, further supporting that these households were in a monga crisis. At endline, significantly more non-participating households reported family migration, with more than a three-fold increase from baseline to endline and a three-fold increase compared to the CFWparticipant households. CFW-participant households showed no change from baseline to endline with respect to family member migration (Figure 11). This indicates that the CFW intervention was effective in negating the negative trend of family migration. Besides the economic benefit to participating households preventing migration also has positive impact on family stability and social cohesion. 20

22 Figure 11. Proportion of CFW-participant and non-participant households where some members migrated to cope with monga at baseline and endline 50 Baseline Endline 40 Proportion (%) CFW-Participant Non-participant 21

23 4. Conclusions The research findings showed that at baseline an equally high proportion of households were already experiencing monga however, in households who had improved access to social protection, in the form of the CFW intervention there was no impact on nutritional status. This may be due to the short duration (25-30 days) of the intervention. However, at endline a higher proportion of women who were employed in CFW were moderately to severely malnourished than those women who were not employed in CFW. This observation does call into question the high energy demands of the hard physical labour of this CFW intervention. The findings also suggest though not conclusive (not statistically proven) that there may be some deterioration in the nutritional status of children from households where the mothers were employed in CFW interventions. Potentially this impact might be largest on breastfeeding infants. Despite the lack of statistical proof for these two negative attributes of the CFW programme, they should serve as timely reminders that future CFW programmes should be developed in a more gender-sensitive manner. The research findings have however provided convincing and conclusive results that the CFW intervention was an effective measure to minimize and negate the negative consequences on monga-affected households which included: Negating the need for households to reduce their meal size or decrease their number of meals by skipping meals Improving the amount and quality of food Allowing better access to high quality animal source foods Allowing more households to increase consumption of a diverse diet Reducing the need to rely on costly short-term coping strategies Negating the need for and effects of family migration Given that at baseline the CFW households were significantly different to the non-participant households with respect to socio-economic status and that at any given point in time CFWparticipant households had lower prevalence of malnutrition than the non-participant households this study did not find results which showed a positive change in nutritional status as a result of CFW. This may also be due to the short duration (25-30 days) of the intervention and the possible off-set of the high energy demands of the hard physical labour of the CFW intervention. 5. Recommendations o In the future, CLP may want to consider the timing of the baseline survey and the implementation strategy for the CFW intervention in terms of equal time of participation and exiting of beneficiary households from the CFW intervention. 22

24 o In the future, CLP may want to tighten up village selection as well as participant targeting and selection processes; as this study showed that by CLP criteria the comparison group was worse off both in terms of socioeconomic and nutritional indicators than the CFW participant group. o To see possible changes in nutritional status perhaps a study design which includes a longer intervention period of equal length of time amongst participant-households with a follow-up survey at the completion of the intervention and an impact survey one-month after the intervention, could be considered. o Given that the burden of food deprivation is gender-biased towards women a longer duration of the CFW intervention could be explored to understand the negative impact on CFW-participating women in terms of the deteriorating BMI and child nutritional indicators. o Given the high energy demands of the physical labour and the time demands from taking care of their children perhaps other more gender-sensitive interventions and be explored. o Given the trend of decreasing BMI amongst male and female members of CFW participant households involved in intense physical labour, suitable high-energy foodbased interventions and possible low-energy demanding CFW activities could be explored and considered. o Given the highly important indications that the data appears to be showing, some possible negative impacts of CFW on women workers and their young children, CLP should consider publicizing these data by publishing in an international journal. Further, now that we are more aware of these potential pitfalls of CFW interventions, the impact of introducing more gender-sensitive aspects in CLP s future CFW programmes should be monitored and reported. 23

25 Appendix 1: Household Selection Procedures Household selection Household selection for data collection in CFW-participant and non-participant households followed the guidelines described below: Village selection 1. From a list of Unions provide by CLP 15 unions were randomly selected. 2. From each Union 2 villages were selected once CLP verified that CFW activities were planned. 3. If, no CFW activities were implemented as scheduled another two villages were selected with verification from CLP. CFW-participant households 1. From each Union 2 villages were surveyed, from the list of beneficiary provided by CLP, in each village HKI selected 35 households for data collection using random number tables. Since CLP has done the selection of these households, no further criteria were used for selecting the households. 2. In each village up to 35 households were included in the baseline, expecting that fewer households may be available at endline to follow up. 3. In selected households, the CFW-participant, a mother with under five children were included in the survey. If there is more than one mother with children under-five, one mother was randomly selected for interview. 4. Selected households did not always have a child under-five years to be included. In those cases, only the CFW participant and one mother were selected from the HH. Non-participant households 1. Under the selected union, 2 villages that are adjacent to two CLP villages were selected so that data collection areas are more homogeneous. 2. From each village 30 households were surveyed. 3. From the selected villages, households were selected using systematic sampling starting from a central point to select the location of first households to be surveyed. 4. HH were screened and checked to verify that they meet the criteria for selection of control households as described above. Considering that more than 50% of the households have no land at all in this area and households are very scattered, every 3rd households were surveyed from each village in the chars, until completion of 30 households. 24