3.2 Participant characteristics
The first household survey was conducted between July and August 2017. Of the 239 households approached, 222 households consented to completing the questionnaire (response rate 92.9%). Characteristics of the survey population are given in Table 2. Seventy-two per-cent of households were classified as ‘slum’ or ‘non-slum’ based on the UNHABITAT 5-point definition of slum households [25]. Full details of the participants in the qualitative interviews conducted in phase 1 with care-givers (n=16), community leaders (n=5) and in phase 2, with child-care centre users (n=5), non-users (n=3), ex-users (n=3) and staff (2) are presented in Table S2 (supplementary materials). The final specification of the centre following the co-design process and then reshaped during implementation can be found in table S3 (supplementary materials).
Table 2: Characteristics of survey population
|
|
Frequency
|
%
|
Child age (years)
|
|
|
|
1 to <3.5
|
129/222
|
58
|
3.5 to <5
|
93/222
|
42
|
Child sex
|
|
|
|
Male
|
114/222
|
51
|
Female
|
108/222
|
49
|
Primary care-giver role
|
Mother
|
192/211
|
86
|
Father
|
2/211
|
1
|
Sister
|
2/211
|
1
|
Grandmother
|
13/211
|
6
|
Other
|
2/211
|
1
|
Primary care-giver education status
|
|
|
|
Illiterate
|
41/222
|
18
|
Literate
|
181/222
|
82
|
Primary care-giver occupation
|
|
|
|
‘Housewife’ - not working outside household
|
182/220
|
83
|
Skilled worker
|
19/220
|
9
|
Unskilled worker
|
19/220
|
9
|
Missing
|
2/222
|
|
Household statusa
|
|
|
|
Slum
|
160/222
|
72
|
Non-slum
|
62/222
|
28
|
Duration living in the area
|
|
|
|
Less than a year
|
13/215
|
6
|
1-2 years
|
20/215
|
9
|
3 years or more
|
182/215
|
85
|
Missing
|
7/222
|
3
|
Missing values are excluded from frequencies and percentages. a Based on UNHABITAT definition (UNHABITAT, 2007)
|
i) Perceptions: Child benefits
Within our theory of change (see Fig. 1), we identified the potential for positive ECD, health and safety outcomes for children. Within our findings we identified how these elements were perceived across participant groups and methods.
Early childhood development (ECD): There was a disconnect between parents and policy-makers in terms of understanding and priority given to ECD. Interviews with parents and community members highlighted how their priority was the academic aspects of ECD, with a focus on literacy and numeracy. Policy makers felt parents and the wider community rarely appreciated the wider social, emotional and cognitive aspects of ECD:
“Because in our country, we see that the meaning of children’s care to most of our mothers is only providing the children’s food and bath. They don’t have any idea about other factors besides that.” (Policy-maker 03 SSI, ECD expert)
Parents frequently expressed concerns about the care they were able to provide due to the demands of their working lives in the city, and in particular, how this would impact on their child’s education:
“At the moment, care is just about giving a child proper food, giving them a proper bath, making sure they sleep on time…. Besides that, they must get a proper education. I started teaching my other children when they were 2 years old. But I could not teach her even a simple rhyme and she’s already 3 years…. I just can't give her much time. I leave home at 9am and get back at 10pm.” (M-016 SSI: mother, slum-household)
Grandmothers were identified as regular secondary care-givers in the interviews and 6% of primary care-givers in the survey. However, the care they provided frequently did not meet the parents’ child-care aspirations, particularly in terms of educating the child:
“Definitely, it’s not how I want it to be. The thing is, my mother is an uneducated, older woman so neither can she teach him anything, nor does she even try to teach him anything. She does her own things all day, she just feeds him and gives him bath, that’s all.” (M019 SSI: mother, non-slum, school assistant)
There was, however, considerable variation in how our participants interpreted ‘education’. The discussion among participants in the co-design focus group illustrated how some mothers clearly gave a high priority to learning specific subjects, while others focused on learning rhymes. While they mentioned how children love to play, none explicitly mentioned playing with their own children:
PI:“I think there should be three teachers. One should teach Bangla, one English and the other maths.
P2: No, no sister, it is not possible. You have to understand, the children will learn the alphabet, rhymes, no separate teacher is necessary for that.
P4: Exactly, the children will study different subjects on different days… they don’t have to study all the subjects every day.
P6: Right, the children should be taught along with their playing games. If they are only made to study, they will be unwilling to go to the centre anymore.
(Co-design focus group discussion)
The survey suggested that despite pre-primary not starting until 5 years old, several under-5s were attending school, with 10% (95% CI: 5%-19%), already enrolled in a school or Madrasah and 14% (95% CI: 6%-30%) planning to enrol soon.
Religious education: The desire to provide a good religious upbringing for their children was a common aspiration among parents. Within the ward there were privately run Quomi Madrasahs and Alia Madrasahs which provide Islamic education alongside the government curriculum [32] and Furkania or Hafizia Madrasah where children of 3 to 4 years learn to recite the Holy Quran [33]. We found the Madrasah education system was highly valued, particularly among fathers, as it delivered religious instruction whilst also offering a free child-care service often with food provided.
“There are many Mosques and Madrasahs in this area – I like these institutions. I enjoy the scene of the little children going to Mosque and Madrasah every day.” (F-256 SSI: father, slum-household, factory worker) and “I will try my best to make the boy Maulana [graduate of Islamic education].” (F-172 SSI: father, slum-household, factory worker).
For some, centre-based care was seen as detrimental to religious education and child development:
“Initially, most people would think very negatively about these types of places [child-care centres]. They think the children who stay there will watch something they shouldn’t watch; and their name will be erased from the list of Muslims. They consider it to be an ‘orphanage’. It makes me feel bad.” (F063 SSI: father, slum household, shop- keeper).
Health and safety: In our survey, we found 24% (95% CI: 15-36) of children had had an injury and 69% (95% CI: 59-78) an illness in the last six months. We found no significant associations with childhood injuries; however, we found a statistically significant, modest positive association with being female versus male and childhood illness (adjusted odds ratio (AOR: 1.9, [95% CI: 1.2, 3.1]) and a significant, modest positive association with those care-givers who said they needed a secondary care-giver compared to those who did not (AOR: 1.5, [95% CI: 1.1, 2.2]). Conditions within the urban neighbourhood, coupled with the challenges of supervising children, may help to explain the frequency of injuries:
“There is no open space for children to play in this area, there are no fields. Children have to play in the street or the lane. The roads in this area are very narrow and uneven. Kids have real difficulty playing safely.” (F-256 SSI: father, slum household, factory worker)
ii) Perceptions: Social capital and trust in an urban environment
Social aspects of the urban environment also influenced child-care practices and perceptions of centre-based care. The findings from across all methods highlighted low levels of trust and fearful attitudes towards others living within the neighbourhood, with serious concerns for the safety and behaviour of their children. A common concern was the influence of ‘bad’ friends:
“These children love to play with others and end up learning abusive language and bad behaviour.” (CL IMAM SSI: Male, community leader: religious leader)
“But some mothers can only go to work if they keep their kids at home alone or with elderly grandparents and then the problems arise. After some time, the kids will just go outside and play with bad friends.” (M-172 SSI: mother, slum-household, business)
Concerns about the safety of the neighbourhood and lack of extended family led to difficult child-care decisions for parents. Interestingly, and possibly reflecting low levels of reciprocity and trust within the community, none of the participants mentioned leaving their children with neighbours, even when this meant not allowing children out of the house for fear of their safety.
“No, this place is not safe. Often children go missing. No one knows who anyone is, where they are going and what they are doing. … Often I hear the announcement on the microphone that a child has gone missing.” (M018 SSI: mother, non-slum, housewife)
The community leaders explicitly mentioned these concerns as something that would undermine enrolment in the centre-based child-care centre:
“Suppose, I gave my baby there [the child-care centre] and he or she was smuggled. It is better to play in the streets than that… Such fear really affects the people.” (CL IMAM SSI: Male, community leader: religious leader)
These concerns were reflected in the questionnaire results with the most common reason for not wanting to enrol in a child-care centre was concern that they would be supervised by an unknown person (46% [95% CI: 28%-65%]).
Phase 2 of our study found that despite these underlying concerns, users built up their trust as they became more familiar with centre staff and practices. As the mother below explains, her husband’s attitude changed after her child had attended the centre for several months:
“My husband first said ‘no’ because the centre is unknown. He said, ‘Do not admit her, keep her close’. I said: “now everyone’s child is there, and they do not face any problems, so my child won’t have any problems either. My child will study properly. My husband did not say anything then. He goes there sometimes, just to watch them. Now he likes it too.” (User03 SSI: mother)
Interviews with community leaders highlighted social divisions within the neighbourhood, with the needs of tenant migrants, or ‘floating-people’ who have no voting rights and little voice within the community, rarely taken into consideration:
“I am not sure whether this area requires a child-care centre….There are some floating people in this area who rent houses and are mostly labourers. They could be day labourers … they live from hand to mouth; they may need a centre. For the permanent residents, these mothers don’t have to work or be day labourers, which could cause them to keep their child with someone else or, in an institution. I am working as a public representative for last two years and no one has come to me with this problem to seek a solution (CLWC SSI: Male, community leader: elected official)
Another factor undermining social capital was the high mobility of urban residents. Our second survey found 41% (95% CI: 31%-52%) of families had moved house in the six months since the base-line survey with 13% (95% CI: 8%-20%) moving outside Dhaka 10% (95% CI: 4%-22%) within the ward, 73% (95% CI: 59%-83%) within the Mahalla and 4% (95% CI: 1%-14%) elsewhere in Dhaka (table 3).
Table 3: Phase 2 household survey: Follow-up of base-line survey participants at 6 months
Variable
|
Frequency/total
|
% (95% CI)
|
Previous respondents who could be traced by either mobile phone or household visit
|
Yes
|
159/222
|
72 (59-82)
|
No
|
63/222
|
28 (18-41)
|
Agreed to participate in a questionnaire interview about their situation, child, centre-based child-care needs.
|
Yes
|
125/159
|
79 (72-84)
|
No
|
30/159
|
19 (13-27)
|
Don’t know
|
4/159
|
3 (1-5)
|
Missing
|
63/222
|
28
|
iii) Perceptions: Family first
Despite the apparent need for child-care, centre-based care was still seen as a last resort, only to be used if care was not available from a family member. The continuation of traditional perceptions that women, either as a mother, grandmother or aunty should be the main care-giver was evident. Centre-based child-care was the last resort, once support from female relatives and older siblings had been exhausted, this was particularly evident in interviews with male community leaders and fathers:
“If the sister-in-law or the mother-in-law of the wider family is unwilling to look after the child, then parents would have no other choice but to keep their child in a child-care centre. But, this could result in a bad relationship with their family.” (CL LP SSI: male, community-leader elected official)
Despite these traditional norms of women as the ideal care-givers, the interviews highlighted how with more women working outside the home, some fathers were taking an active role in child-care. Despite the potential for changing gender norms, none of the participants explicitly mentioned the role of fathers in providing child-care.
iv) Demand: Work and childcare
We found a high level of demand with 84% (95% CI: 74%-91%) of survey respondents willing to pay to enrol their under-5 child in centre-based child-care. Furthermore, 24% (95% CI: 16%-37%) of care-givers, the majority of whom (86%) were mothers, reported previously turning down paid work due to lack of child-care. We found a significant, large, positive association with wishing to enrol in centre-based care and being from a slum versus non-slum household (AOR: 3.8 [95% CI: 1.4, 10]) (Table 4).
Interviews with community leaders helped to explain the increase in poorer, slum households as established home-owners moved out of the area, renting out their houses to factory workers. The shifting population had led to changes in family structures, with fewer large, extended families. For working parents this lack of extended family led to significant child-care challenges.
“So, the husband and wife of most of the families have to work outside the home… suppose they have three children and the elder child is eight or ten years old, then the parents really depend on that elder child, leaving their younger child under their responsibility.” (CLBM SSII, male, community-leader: business).
Table 4: Demand for centre-based child-care and relationships with child, care-giver and household characteristics
|
|
Prepared to enrol in centre-based child-care
|
Prepared to pay for centre-based child-care
|
Prepared to pay extra to subsidise centre-based child-care for children from low-income families
|
|
|
n
|
% (95% CI)
|
AOR (95% CI); p-value
|
N
|
% (95% CI)
|
AOR (95% CI); p-value
|
n
|
% (95% CI)
|
AOR (95% CI); p-value
|
All households
|
|
136/215
|
63 (48-76)
|
NA
|
187/222
|
84 (74-91)
|
NA
|
92/169
|
54% (35-73)
|
NA
|
Slum/non-slum status of household
|
|
|
|
|
|
|
|
|
|
|
Non-slum
|
27/59
|
46
(24-69)
|
Ref
|
46/62
|
74
(52-89)
|
Ref
|
30/44
|
68%
(31-91)
|
Ref
|
Slum
|
109/156
|
70
(56-81)
|
3.8 (1.4, 10); 0.016
|
141/160
|
88
(80-93)
|
2 (0.8, 4.9); 0.1
|
62/125
|
50%
(32-67)
|
0.6 (0.3, 1.1); 0.08
|
Age (child)
|
|
|
|
|
|
|
|
|
|
|
3.5 to <5
|
43/89
|
48
(31-66)
|
Ref
|
73/93
|
78
(70-85)
|
Ref
|
44/70
|
63%
(37-83)
|
Ref
|
1 to <3.5
|
93/126
|
74
(61-84)
|
2.9 (1.4, 6.2); 0.013
|
114/129
|
88
(70-96)
|
1.9 (0.5, 6.8); 0.25
|
48/99
|
48%
(31-67)
|
0.6 (0.2, 1.1); 0.11
|
Sex (child)
|
|
|
|
|
|
|
|
|
|
|
Female
|
63/105
|
60
(40-77)
|
Ref
|
91/108
|
84
(75-91)
|
Ref
|
47/83
|
57%
(34-77)
|
Ref
|
Male
|
73/110
|
66
(54-76)
|
1.7 (0.9, 3.3); 0.1
|
96/114
|
84
(68-93)
|
1.4 (0.9, 5.4); 0.56
|
45/86
|
52%
(34-70)
|
0.9 (0.5, 1.7); 0.68
|
Need secondary care-giver
|
|
|
|
|
|
|
|
|
|
|
No
|
87/148
|
59
(43-73)
|
Ref
|
124/152
|
82
(71-89)
|
Ref
|
60/111
|
54%
(40-68)
|
Ref
|
Yes
|
46/63
|
73
(52-87)
|
2.4 (1.1, 5.2); 0.032
|
60/66
|
91
(80-96)
|
2.2 (0.9, 5.4); 0.07
|
30/55
|
55%
(24-82)
|
1 (0.3, 4); 0.94
|
Primary care-giver (PCG) working
|
|
|
|
|
|
|
|
|
|
|
No
|
112/177
|
63
(47%-77%)
|
Ref
|
155/184
|
84
(71-92)
|
Ref
|
77/136
|
57%
(36%-75%)
|
Ref
|
Yes
|
24/38
|
63
(45-78)
|
0.6 (0.3, 1.2); 0.11
|
32/38
|
84
(72-92)
|
0.6 (0.2, 1.9); 0.35
|
15/33
|
45%
(29%-63%)
|
0.7 (0.3, 1.5); 0.27
|
PCG ever missed work due to lack of childcare
|
|
|
|
|
|
|
|
|
|
|
No
|
95/153
|
62
(48-74)
|
Ref
|
131/158
|
83
(73-90)
|
Ref
|
68/118
|
58%
(40-74)
|
Ref
|
Yes
|
39/53
|
74
(52-88)
|
1.1 (0.4, 2.8); 0.83
|
48/53
|
91
(81-96)
|
1.4 (0.7, 2.9); 0.26
|
17/44
|
39%
(14-70)
|
0.5 (0.2, 1.7); 0.23
|
PCG education status
|
|
|
|
|
|
|
|
|
|
|
Literate
|
108/174
|
66%
(48-80)
|
Ref
|
151/181
|
83 (7-91)
|
Ref
|
78/135
|
58%
(34-78)
|
Ref
|
Illiterate
|
28/41
|
62 (48-74)
|
0.8 (0.3, 2.1); 0.66
|
36/41
|
88 (58-97)
|
1 (0.2, 5.9); 0.97
|
14/34
|
41% (31-52)
|
0.5 (0.2, 1.1); 0.08
|
Missing cases are excluded from frequencies and percentages. Confidence intervals for percentages are logit transformed and account for the clustered survey design. AOR = adjusted odds ratio. Ref = reference group for categorical variable effect comparison. For each outcome the adjusted odds ratios, their 95% confidence intervals and associated p-values are obtained from a logistic regression model (that accounts for the clustered survey design) including all listed covariates, excluding missing cases (complete cases for models: prepared to enrol in centre-based child-care = 195/222, prepared to pay for centre-based child-care = 210/222, prepared to pay extra to subsidise centre-based child-care for low socio-economic status children = 161/222).
|
A common strategy for working mothers, particularly single mothers, was to take their young children to work with them. Only one of the parents interviewed, who worked in a local school, had child-care provision at work. For those with no such provision, attempting to work whilst caring for the child was seen as detrimental to both the child and their work:
“I have to take my child with me when I’m selling the cloths. When my daughter was 5 months old, from that age I used to keep her on my lap wherever I go. And even when I go to work , I had to take my child with me, this is difficult and painful for me.” (M 172 SSI: mother, slum household)
Such strategies were clearly challenging and could lead to job-loss, as one woman who used our child-care centre, reflected:
“I cannot do anything properly when my child is at home. Now my daughter is going to the centre regularly and I don’t have any problems with my work. Before if I went to work, I had to take her with me. She would make mischief and people at work got angry and they scolded her. I quit a job angrily because of that; a good job in a factory.” (Child-care centre user 03)
Even when adult family members were available to take care of children, parents still faced challenges when either the child or the carer became sick or unable to provide care:
“But if her grandparents become sick or if they go to village for some reasons, then it becomes very difficult for me to take care of her. I face huge problems at work, I have to take leave and stay at home, I cannot go to work then.” (FGP3 FGD: Mother, factory-worker)
The qualitative interviews highlighted how, while some participants identified as housewives (83%, see table 1), they were still attempting to earn some income at home by making sweets, handicrafts and sewing. Several of the women who used our centre were able to increase their income-generating work at home. The category of ‘housewife’ within the survey may well have underestimated the proportion of women attempting to earn an income without working outside the home.
iv) Feasibility: Fees, food, hours and engagement
We adapted the initial rural centre-based child-care model following results of the phase one survey, the advice of the steering group and the co-design focus group with eight mothers. The specification of the resulting centre model is provided in figure 1 and in table S3 in the supplementary materials. Specific adaptation to the rural model included long open hours (8am-5pm) to cover parents’ working day, the facilities needed to store and prepare food and increased provision for children under 3.5 years such as sufficient potties and specific training of providers.
Throughout the implementation of the model in phase 2, we planned to hold monthly user-group meetings with parents to enable re-design of centre features in line with their needs and suggestions. Despite our attempts to arrange monthly meetings, the long-hours worked, multiple caring and household commitments (e.g. household gas supply was erratic, meaning mothers had to stay at home to cook if gas availability coincided with the time of the user-meeting) meant that we were only able to hold three meetings during the year of implementation (Supplementary materials: table S4).
Despite the demand for the centre being highest among slum households (AOR 3.8 [95%CI 1.4-10]), survey respondents specified they could pay a mean amount of 218 takka (95% CI: takka 187 -249) per month or ~ $2.55 US dollars (95% CI: $2.19-$2.92) with no food provided and 283 takka (95% CI: takka 185-382) per month or ~ $3.30 (95% CI: $2.17-$4.47) with food. Initially a minimal fee of 200 takka/month (~$2.40) was charged when the centre opened, however, enrolment was low in the early months of implementation and feedback from the user-group highlighted how even paying a minimal fee of 200 takka was seen as too much by many families. To boost enrolment among poorer families, the fee was removed.
We often found contradictions between the findings from the different methods (questionnaire, qualitative interviews and users’ group meetings) on parents’ specifications for the centre-based child-care centre. Most fundamentally, while the initial survey suggested a high demand for centre-based child-care, we found that throughout the 10-month implementation period we were not able to fill the centre to its capacity of 25 children. Enrolment varied per month, starting slowly with only 8 children and reaching a maximum of 22 children by the fifth month. Over the 10 months, a total of 35 children used the centre, the majority of whom (63%) came from slum households [25]. Seasonal changes and religious events influenced demand:
“We are experiencing drop-out because it is the month of Ramadan. Only eleven or twelve children come here every day. It is decreasing because most of the people are tenants here. Some are returning to the village again some are moving back home.” (SSI Centre staff member)
Finding ways to provide nutritious food within the limited space and budget of the centre was a key challenge. The initial survey indicated that 92% (95% CI: 83-96) were willing to provide food. However, this led to challenges within the centre with some children having more, and tastier, food than others. Staff and the user-group felt this undermined the spirit of equity within the centre and there was concern for nutritional adequacy for poorer children but also concern that any fees would deter these families. It was agreed that the only way to continue to provide care for children of poorer households was the provision of snacks (fruit, eggs, bread) at no extra cost. This placed a further challenge to the sustainability of the centre. Further details of the issues raised in the user-group can be found in supplementary table S 4.
As summarised in figure 2, the findings from both phases of the study shed light on why, even with no fees, sustaining enrolment at the centre was challenging. The inter-relationships between the urban social and physical environment, perceptions of appropriate providers of child-care based on gender-norms and value placed on education and religion, rather than holistic ECD, influenced parents’ willingness to use centre-based care.