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 childrens 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). 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.

3
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. Folmars 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

4
 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 Masters 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

5
 References

Bennett, L. (2005). Gender, caste and ethnic exclusion in Nepal: Following the policy process from analysis to action. New

Frontiers of Social Policy, Arusha. 12-15.

Coates, J., Swindale, A., and Bilinsky, P. (2007). Household food insecurity access scale (HFIAS) for measurement of food

access: Indicator guide (v.3) No. 3). Washington, D.C.: Food and Nutrition Assistance Technical Project.

Fleiss, J. L. Table A.3. Sample sizes per group for a two-tailed test on proportions. Statistical methods for rates and proportions

(Second ed., pp. 273). USA: John Wiley and Sons.

Folmar, S. (2007). Identity politics among Dalits in Nepal. Himalaya, XXVI (1-2), 41-53.

Gittelsohn, J. (1991). Opening the box: Intrahousehold food allocation in rural Nepal. Social Science & Medicine, 33(10), 1141-

1154.

Goyal, R., Dhawan, P. and Narula, S. (2005). The missing piece of the puzzle. Caste discrimination and the conflict in Nepal.

NYU: Center for Humans Rights and Global Justice. Retrieved from

http://www.chrgj.org/docs/Missing%20Piece%20of%20the%20Puzzle.pdf

Gurung G. Social Determinants of Protein-Energy Malnutrition: Need to Attack the Causes of the Causes. J Health Population

Nutrition. 2010; 28(3) : 308-309.

Pradhan, A., Aryal, R.H., Regmi, G., Ban, B. and Govindasamy, P. (1997). Nutritional status of children. Nepal family health

survey 1996 (pp. 148). Calverton, Maryland USA: Macro International Inc.

Prasai, Y. and Aryal, R.H. (2007). Child health. Demographic and health survey 2006 (pp. 157). Calverton, Maryland, USA:

Macro International Inc.

Satcher, D., Fryer, G.E., McCann, J., Troutman, A., Woolf, S.H., and Rust, G. (2005). What if we were equal? A comparison of

the black-white mortality gap in 1960 and 2000. Health Affairs, 24(2), 459-464.

Save the Children. (2009). Hungry for change. An eight-step, cost of action to tackle global child hunger. London, UK: Save the

Children.

6
Schmid, M.A., Egeland, G.M., Salomeyesudas, B., Saatheesh, P.V., and Kuhnlein, H.V. (2006).

Traditional Food consumption and nutritional status of dalit mothers in rural Andhra Pradesh, south India. European

Journal of Clinical Nutrition, 60(11), 1277-83.

Stone, L. (1978). Cultural repercussions of childlessness and low fertility in Nepal. Centre for Nepal and Asian Studies, 5(2), 6-

35.

UNDP. (2005). Nepal millennium development goals (Progress report. Kathmandu, Nepal: HMG Nepal. Retrieved from

http://www.undp.org.np/publication/html/mdg2005/mdg_npl.pdf

Venkatesan, S. (2007). Caste violence and Dalit deprivation in India A capability approach. (PhD Scholar, Centre for

Development Studies, Trivandrum, India).

WHO (2006). The WHO child growth standards. Retrieved 1/11/11, 2011, from http://www.who.int/childgrowth/standards/en/

Williams, D.R., and Jackson, P.B. (2005). Social sources of racial disparities in health. Health Affairs, 24(2), 325-334.