Sustainable day-care for 1-4 year olds in disadvantaged urban communities in Dhaka, Bangladesh

Lead Research Organisation: University of Leeds
Department Name: School of Medicine

Abstract

Our partners, CIPRB, have shown, through a natural experiment, that community day-care for 1-4 year old children in rural areas is effective in reducing risk of all-cause mortality by 44%, drowning by 82% and injuries by 88%, compared to children not in day-care [9]. We wish to adapt this model so it can be appropriately, feasibly and sustainably delivered to benefit urban disadvantaged communities.
Low-income countries (LICs) are experiencing rapid and uncontrolled urbanisation. This can clearly be seen in Dhaka, Bangladesh with an annual urban population growth of 3.6% [6], and an estimated 4 million inhabitants living in slums. Urbanisation is changing gender dynamics: 22% of women in Dhaka now work outside the home (11% non-slum) [9]. With limited extended family support in slums, women must either leave children with elder siblings - often sisters who then drop-out of school - or neighbours. This limited supervision contributes to high rates of injuries, poor hygiene and limited nutrition, resulting in 50% of slum children suffering stunting (33% non-slum). Child day-care presents a holistic solution, allowing women to work whilst knowing their children are safe, cared-for and have opportunities for early childhood development (ECD).
Our partners, CIPRB, have extensive experience of delivering day-care in rural Bangladesh [9]. Building on CIPRB's rural model we plan to develop and refine a sustainable day-care model based on principles of ECD and improving nutrition and hygiene for 1-4 year olds. Financial sustainability is key for longevity and scale-up. We plan to place day-care centres adjacent to slums so services at a suitable fee can be provided to parents in non-slum neighbourhoods. This approach is designed to promote integration between the two communities, potentially facilitating social mobility for slum children.
Objectives and methods, to:
1) Understand the extent and nature of demand for day-care we will survey 200 households with children under 5 from slum and non-slum communities, and conduct qualitative interviews to understand perceptions of childcare among women, carers, men and community leaders.
2) Co-produce a proto-type integrated, self-sustaining, child day-care model we will establish a technical working group of childcare experts, community representatives, local government officials, donors and (I)NGOs. The group will draw on CIPRB's, (I)NGO models and findings of a systematic review being conducted by UWA (not included in this proposal) to develop a prototype model and all materials required. The group will also develop a draft theory of change to guide the evaluation.
3) Test and refine an integrated self-sustaining model, we will implement the day-care model for six months. During this time, we will facilitate a group of day-care users and staff to reflect on how the model is working and make changes for improvement. Our qualitative researchers will observe the process, and interview users to understand how to further improve the model. We will assess model costs and the extent that fees from non-slum day-care users can support sustainable delivery.
4) Inform the design of a pilot study for a larger evaluation to assess the cost-effectiveness of the day-care model, we will assess the feasibility and then refine methods for recruitment, assessment and follow-up among day-care users and a potential comparator group. This will involve repeating the survey among the same sample of 200 households. We will also assess children when they start at day-care and six months later. We will use our overall analysis to refine our theory of change. Throughout the study we will engage closely with local government and donors to understand and influence plans to scale up day-care across Dhaka, targeting the urban poor. We will identify the most appropriate outcome measures from our theory of change and discussions with policy makers. We expect these will include ECD, stunting and injuries.

Technical Summary

Low-income countries are experiencing rapid and uncontrolled urbanisation [1;4]. With a population of 16 million, a quarter of whom are slum-dwellers, Dhaka, Bangladesh exemplifies this transition. The poor infrastructure and conditions of slums limit child health and development [2; 3; 9]. Increasing numbers of urban poor women are working outside the home [9], often leaving children with limited supervision. The 1-4 year age group are particularly vulnerable to injuries, poor nutrition and infections, yet intervention at this age can positively impact physical and cognitive development [2;5]. A 2011 systematic review showed day-care improved early childhood development (ECD), but also identified no robust studies of urban day-care in Asia or Africa, and insufficient quality evidence to assess health outcomes. Our partners, CIPRB, have shown that community day-care for 1-4 year olds in rural Bangladesh is effective in reducing all-cause mortality by 44% (95% CI: 20% to 61%), drowning by 82% (95% CI: 42% to 94%) and injuries by 88% (95% CI: 61% to 96%) compared to children not in day-care [9]. We wish to adapt this model so that it can be appropriately, feasibly and sustainably delivered to benefit urban disadvantaged communities.

This early phase study will: (1) use a survey and qualitative interviews to understand the extent and nature of demand for day-care amongst slum and non-slum households. (2) Co-produce, with communities, government and NGOs, a proto-type self-sustaining, child day-care model focusing on ECD, nutrition and hygiene improvement. (3) Use participatory action research to test and refine the model in one of Dhaka's largest slums. (4) Assess the feasibility and then refine methods for recruitment, assessment and follow-up among day-care users and a potential comparator group. The outcomes of this research will inform the design and pilot testing of a future evaluation to assess the cost-effectiveness of the day-care model.
 
Description Day-care has the potential to provide multiple benefits to children, families and societies. With rapid urbanisation, increasing numbers of women, particularly in low-income households, are working outside the home with reduced support from extended family. This social and economic transformation has left a day-care vacuum in many low and middle-income countries. We aimed to identify existing provision of day-care for poor, urban households, understand demand and perceptions of day-care in Dhaka, Bangladesh. We co-produced and piloted a day-care model over a nine-month period, documenting implementation. Sequential mixed methods included an initial survey (n=222) of households with under-5 children and qualitative interviews with primary care givers (n=16) and one focus group with mothers, day-care centre providers (=4), policy makers (n=5) and community leaders (n=5)
We found 24% (95% CI: 16%-37%) of care-givers reported turning-down paid work due to lack of child-care , 63% (95% CI: 48%-76%) were willing to enrol their under-5 child and pay a mean of 283 Takka (£2.50) per month, with 38% (95% CI: 20%-61%) willing to subsidise poorer children. Slum households were over three times more likely to report needing day-care than non-slum (AOR: 3.8, 95% CI: 1.4-10), as were those with children below 3.5 years (AOR 2.9, 95% CI: 1.4-6.2) compared to 3.5 to 5 years. Qualitative findings identified the impact of the urban environment on child-care through changing gender norms and working patterns, low social capital and fears for child safety. These influences interacted with religious, cultural, social norms and a low priority given to early childhood development, resulting in caution in using day-care despite evident need.
Exploitation Route To inform future studies assessing the impact of day-care on a health and social outcomes. To inform delivery of day-care for urban poor communities and inform government policy and resource allocation.
Sectors Communities and Social Services/Policy,Education,Healthcare

 
Description ESRC International Development NGO Data: Impact Acceleration Account Additional Funding
Amount £30,000 (GBP)
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 05/2018 
End 06/2019
 
Description Improving day-care through communities of practice in informal settlements in Nairobi
Amount £293,000 (GBP)
Funding ID ECE190115 
Organisation The British Academy 
Sector Academic/University
Country United Kingdom
Start 11/2019 
End 10/2021
 
Title Urban Day Care Methods Manual 
Description The methods manual describes all quantitative and qualitative methods to be used in the study, including mindmaps that have been developed and reshaped to understand day-care issues to inform methods and analysis. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact Consistent use of the methods across the organisations involved in the study. 
 
Description Day care ECD network event at University of Leeds 
Organisation London School of Hygiene and Tropical Medicine (LSHTM)
Country United Kingdom 
Sector Academic/University 
PI Contribution We organised a days workshop for research groups working on early childhood development and day-care in Africa and Asia
Collaborator Contribution Partners from LSHTM, World Band, African Population and Health Research Council and DFID shared their current work on ECD and any research findings.
Impact Multi-disciplinary with Education, health Led to two sister funding applications being submitted
Start Year 2019
 
Description ECD Network Bangladesh 
Organisation Bangladesh Early Childhood Development Network
Country Bangladesh 
Sector Charity/Non Profit 
PI Contribution Dr Mashreky Saidur has been a leading member of the ECD network in Bangladesh. He has shared the findings of our study and our work to categorise Bengali activities and games for under 5s against ECD domains. This has influenced the development work of the ECD network in proposing an ECD curriculum for Bangladesh. He has also commented on the Day-care and ECD government strategy.
Collaborator Contribution the ECD network has provided a valuable channel through which to influence Ministry of Women and Children and other government departments in Bangladesh.
Impact A manual so ECD activities for under 5s in Bangladesh is under-development.
Start Year 2017
 
Description DFID Bangladesh health advisor meeting 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Helen Elsey, Saidur Mashreky and Rumana Huque met with DFID Bangladesh health advisor in Dhaka on 1st November 2017 to discuss the importance of day care within the urban context. This triggered a request from DFID to submit a concept note on day-care for the urban poor to inform the development of their forthcoming 5 year urban health strategy.
Year(s) Of Engagement Activity 2017
 
Description Early childhood development measures 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The Anchal team (particularly CIPRB and Leeds) have engaged with the World Bank ECD group, STC ECD group as well as developers of ECD assessment tools including the CREDI tool, MELQO and IDELA tools. We have agreed to share data on their use and implementation in the urban Dhaka context.
Year(s) Of Engagement Activity 2017,2018
 
Description International Conference on Urban Health 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Helen Elsey (PI of SUE project) with HERD/CIPRB/ ARK/HUPH/UoL presented a poster titled "Defining Households and Understanding Poverty in Urban Slums: Informing Survey Design in Nepal, Bangladesh and Vietnam" at the International Conference on Urban Health, Coimbra, Portugal (26-29 Sept 2017). As a result of contacts made at the ICUH, Helen was invited to 'Bellagio Conference' Italy in Nov 2017 to agree global definitions of slum areas. Helen also presented poster entitled Understanding child-care and early childhood development in urban slums: a mixed methods study from Dhaka, Bangladesh
Authors: Helen Elsey, Mahua Das and Joe Hicks (University of Leeds, UK); Rumana Huque, Shammi Badrul, Fariza Fieroze (The ARK Foundation, Bangladesh) ; Hilary Wallace (University of Western Australia) Riffat Shawon, Sylvia Junnatul Ferdoush and Mashreky Saidur (CIPRB, Bangladesh)
Year(s) Of Engagement Activity 2017
URL http://www.icuh2017.org/
 
Description Participatory Panel Health Systems Research Conference Liverpool October 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact A panel of researchers and policy makers presenting experiences and research on working across sectors and through non-health care settings to improve the health of the urban poor. We shared a video of the urban anchal project. This triggered much debate about expanding health systems to include non-health care settings.
Year(s) Of Engagement Activity 2018
URL https://www.youtube.com/watch?v=w1Kogwq4hXY
 
Description Presentation of Urban Anchal Findings ICUH 2018 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact The presentation of the ANchal findings triggered considerable debate particularly amongst policy makers and donors at the International Conference on Urban Health 2018 in Kampala. Day-care has received limited attention, and yet participants could clearly see the value of targeting under 5 s in day-care for improved health and social outcomes.
Year(s) Of Engagement Activity 2018
 
Description RNLI engagement 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact Helen Elsey has engaged with the drowning prevention officer at RNLI on several occassions including visiting the RNLI offices in Poole, 22nd September to discuss the urban Anchal project with RNLI drowning prevention and ECD advisors. RNLI are supporting a major initiative in rural, delta region of Bangladesh to provide community day-care. We have agreed to jointly advocate for day-care where possible. RNLI are involved in global drowning prevention initiatives so have strong potential to influence WHO and UN policy on day-care.
Year(s) Of Engagement Activity 2017
 
Description Regional Public Health Conference, Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact ARK Foundation and CIPRB (Bangladesh) participated in 8th Public Health Conference organized by Bangladesh University of Health Sciences on 29th December 2017 to present poster on "Defining Households and Understanding Poverty in Urban Slums: A Qualitative Study to Inform Household Survey Design in Nepal, Bangladesh and Vietnam". Dr Shawon Riffat (CIPRB) also presented a poster entitled : Understanding child-care and early childhood development in urban slums: a mixed methods study from Dhaka, Bangladesh
Year(s) Of Engagement Activity 2017
 
Description Urban Day-Care India 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Third sector organisations
Results and Impact Mahua Das (Research Fellow UoL) working on the urban day-care project Bangladesh (MRCPHIND) has been engaging with organisations (Ekjut, PHRS) in India to develop similar day- care model for under five children in the urban slums in Jharkhand
Year(s) Of Engagement Activity 2017
 
Description Urban Day-Care steering group 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact Two steering group meetings have been held. These have included participants Prof. AHM Enayet Hussain - (Additional Director General Directorate General of Health Services); Mr Aynul Kabir (Joint Secretary, Ministry of Women and Children Affairs) DG Department of Women Affairs; Brig Gen. (Dr.) Sheikh Salahuddin, (Chief Health Officer.Dhaka South City Corporation) ; Dr. Manzoor Ahmed- (Chairperson Bangladesh ECD network) ; Md Tariqul Islam (ECD specialist
Shishu Academy); MD. Golam Mostafa
(Early Childhood Development Advisor
Aga khan Foundation, Bangladesh); Mahmuda Akhter (Member secretary Bangladesh ECD network) ; Ms. Hosneara Khondker (Manager Early Years Development, Shishuder Jonno Save the Children in Bangladesh); Shamsher Aki Khan (Senior Adviser Sajida Foundation);
Roxana Khanom (Manager Early years development, Shishuder Jonno Save the Children in Bangladesh)

Mr. Mohammad Moshin (ECD specialist
Unicef Bangladesh); Dr. Zaiul Matin (Health Specialist Unicef Bangladesh);
Fahmida Tofael ( Scientist, Child Development Unit, ICDDRB); Mrs. Ahlam Ahsan( Project Manager , Phulki); Mrs. Nigharin Aresfin ( Project Manager, Phulki)
Year(s) Of Engagement Activity 2016,2017,2018
 
Description Urban Health System Conference, Bangladesh 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact ARK were invited to attend the conference, 'Urban Health System Conference' on 28th February 2018. They participated in sessions on the 'Urban Health Systems Strengthening Project' disseminated their 'lessons learned. SUE team member, Tarana Ferdous participated in the conference.
Year(s) Of Engagement Activity 2018