exploring food security and nutrition among young women in

Exploring food security and nutrition among young women in the

garment sector

A cross sectional surveyBy Dr Lwin Mar Hlaing, Dr Kaday and Dr Sophie Goudet,

www.nutritionways.org 2

EXPLORING FOOD SECURITY AND NUTRITION AMONG YOUNG WOMEN IN THE GARMENT SECTOR

Dr. Lwin Mar Hlaing is Deputy Director of National Nutrition Centre (NNC) of Department of Public Health, Ministry of Health and Sports, Myanmar. She attained her bachelor (M.B.,B.S.) in 2003, MPH in 2010 and PhD (Nutrition) in 2014. She is currently leading the national nutrition programmes, nutrition surveillance system and national nutrition laboratory of Myanmar.

Dr. Kaday Kyaw is a medical officer from National Nutrition Centre, Department of Public Health, Ministry of Health and Sports. He got his medical bachelor (M.B;B.S) in 2012. He is working in National Nutrition Programs and Supply and Equipment of NNC.

Dr. Sophie Goudet, is a researcher in nutrition and an academic member of the New York Academy of Sciences, USA. Her previous research has explored nutrition of children and women living in urban settings in low and middle income countries. Recently she has focused her work on the linkages between nutrition, urbanisation and resilience with a growing interest for adolescent and maternal nutrition.

Paula Griffiths is the external chair for this research. She is Professor of Population Health and Co-lead of Loughborough University’s global research challenge in health and wellbeing, School of Sport, Exercise and Health Sciences, Loughborough University, UK and honorary Professor, Faculty of Health Sciences, University of Witwatersrand, South Africa. Her research focuses on inequalities in health outcomes in low and middle income countries and community strategies to reduce these.

The research was approved by the Ethics Review Committee, Department of Medical Research, Ministry of Health and Sports, Myanmar on October 30th, 2018.

Introduction


Sophie Goudet [email protected]



The survey was made possible thanks to the financial contribution of the Sackler Institute for Nutrition Science at the New York Academy of Sciences. The project could not have been successful without the support and contribution of the National Nutrition Centre, Ministry of Health and Sports, and the efforts and commitment of H&M, the factories and participating young women.




In Myanmar, the garment industry contributes to 31% of all manufacturing jobs, and employs more than half of all women working in manufacturing. Young women aged 15 to 19 years old, represent 8% of the total population and make up an important portion of the workforce in factories (MoHS and ICF 2017, ILO 2015). Limited evidence available has suggested that women employed in garment industries face challenges related to food security. Based on a cost of diet survey in Yangon poor urban areas, poor families were not able to afford a nutritious diet (Save the Children 2013). Food is frequently reported as the main source of expenses, amounting to more than half of the daily income. Street food is also widely consumed as household members have limited time to cook in the house due to their work which increases the expenditure on food.

This study provided detailed and robust data on young women working in the garment sector related to nutrition and food security. The findings presented at woman, household and factory level showed that these women can face poor nutrition and food security access issues. The report offers recommendations and identifies areas for interventions.

What we know

What this research adds

31%69%



Young girls’ nutritional needs are critical for the well-being of society. Malnutrition and anaemia can adversely impact their health and development. In Yangon region, girls in the 15 -19 years old age group carry the triple burden of thinness, overweight and anaemia. Young women are largely employed in the garment sector and with the expected continuous expansion of the Myanmar garment industry, there is a need to further assess the food security and the nutrition situation of young women engaged in garment work in poor urban areas.

Why it is important?

In Yangon region, girls in the 15 -19 years old age group carry the triple burden of thinness, overweight and anaemia.



Rapid expansion of industrial zones of West Yangon 2004-2018Source: Google Earth historical imagery



The study used a mixed method approach, cross-sectional study design with a sample size of 546 young women (randomly selected ) from 11 factories to generate evidence on issues related to food security and nutrition. Data were collected in November 2018.

Formative research was conducted via structured interviews with factory managers and food walks to identify food availability around the factories with a radius 1 km in Hlaing Thar Yar and Shwe Pyi Thar townships of Yangon.

Methods

11 factories

546 young women



AT INDIVIDUAL LEVEL:

Young women shared similar characteristics; most had recently moved to Yangon to find better job opportunities. The majority came from regions near Yangon (Ayeyarwaddy and Bago) closely followed by Magway and Rakhine State. These women were newly employed, worked more than 49 hours per week and were provided with various levels of benefits by the factories in terms of housing, food, transport and clothing. One in nine women was absent the previous week from work with sickness as the main cause. They relied predominantly on the private health structure for health care (66%).

Key findings

Ayeyarwady Region

49%

Bago Region

16%

Other

6%

Rakhine State

11%

Mandalay

6%

Magway Region

12%

Percentage of women per state or region of origin

49%

16%

12%11%

6%



Months of migration

There is a peak of migration from April to May which corresponds to the dry season in Myanmar and the start of the lean season.

25

20

15

10

5

0JAN MAR MAY DECOCT NOVFEB APR JUL SEPJUN AUG



Women frequently reported headache (13%), thirst (8%) and hunger (15%). Many demonstrated clinical signs of anaemia in the work environment (8%). 53% did not have good quality nutrition with low diet diversity and high sugar intake.

HEADACHE

Rice, Bread, Potatoes

Dark green leafy vegetables

Beans, pulse, lentils, chickpeas, tofu

Dairy, milk, yogurth

Meat, poultry, fish, shrimp

Other vitamin A rich fruits and vegetables

Sugary drinks

Sugar food consumption

Other vegetables

Eggs

Nuts and seeds

Other fruits

13%THIRST 8%

HUNGER 15%CLINICAL SIGNS

OF ANAEMIA* 8%

Did not have good quality nutrition**

53%

Self reported by participants

Food groups eaten in the last 24h in %

*please refer to the technical notes on anaemia for more details

**based on the Minimum Dietary Diversity Score for Women - refer to the technical notes for more details on the indicator

99.6%

77.6%

37.3%

25.8%

66.8%

33.3%

21.4%

62.0%

32.0%

11.7%

7.1%

30.5%



Employment meant that more women could buy prepared meals but also they had less time to cook and go to the market. Ten percent of the women did not have breakfast before going to work due to lack of time or appetite. The majority of women cooked in the place where they slept and for the rest, either they had no kitchen, did not cook, or had a separated kitchen or lastly used a shared kitchen.

AT THE HOUSEHOLD LEVEL:

Most young women lived in rented houses with three other persons with whom they shared meals. Their wealth was very similar with the other households.

Households food insecurity was low but the nutrition quality of the food eaten at the household lacked protein and iron. Only 15% consumed daily iron rich food in the household (based on the Food Consumption Score - refer to the technical notes for more details on the indicator).

50% of the households experienced food access issues in the past four weeks of the survey related to restricted variety of foods, preference of foods and adequate quantity of food.

Migration and inadequate food access trends over months follow the same pattern with a decrease in January and a steady increase from February to May.

The months of inadequate food access were from the end of the dry season to the rainy season. This corresponds to the peak of migration.

15%

Household Food Insecurity Access Score in %Refer to the technical notes for more details on the indicator

Food secure 50%Mildy food

insecure access 27%Moderatly food

insecure access 14%Severly food

insecure access 8%

Restricted variety of foods: 11.9% of the households were not able to eat the kinds of foods preferred (always or often);

17.2% of the households had to eat a limited variety of foods (always or often)

Preference of foods: 16.8% of the households had to eat some foods they really did not want to eat (always or often)

Adequate food quantity: 3.8% of the households had to eat a smaller meal than they felt they needed (always or often)



Months of inadequate food provisioning in %

40

35

30

25

20

15

10

5

00CT2017

MAR 2018

MAY 2018

DEC2017

JAN2018

NOV2017

FEB 2018

APR 2018

JUL 2018

SEP 2018

JUN 2018

AUG 2018

AT FACTORY LEVEL:

Two factories provided a canteen with subsidized prices and a free fixed menu while the other factories let mobile food stalls come in the premises during lunch time. All factories provided clean eating spaces.

Young women viewed the food options at the factory positively in terms of availability of fruits and vegetables but had mixed views on availability of quality food. Street foods are frequently associated with food-borne illnesses on account of the potentially unsanitary conditions in which food may be stored and prepared. They can also contain high level of fat, trans-fat, salt and sugar.

Near most factories, food outlets provided a wide range of affordable food items all day and all year.



Food walk around a factory

The level of hygiene was low in the food stalls and the main options were teas, coffees, cake, sweets and sweet drinks. There were also a large number of shops selling protein and vegetables at similar costs as the sweet options. Women’s food choices and preferences would be important to further understand.



Food sold by food vendors in %

Fresh Juices

Traditional mixed dishes

Alcoholic beverages

Condiments and flavour cubes

Soups and stews

Sugar and sweet spreads

Processed/fried Meat or poultry

Fat and Oils

Nuts and seeds

Fruits

Modern mixed dishes

Milk and milk products

Roots, tubers, plantain, potatoes

Legumes and pulses

Processed/fried fish or shellfish

Fresh meat and poultry

Fresh fish or shellfish

Savoury snacks and pies

Eggs

Vegetables

Sodas/sweetened beverages

Cakes and sweets

Teas/Coffee

4

4

7

9

9

11

11

15

15

16

16

18

18

22

27

29

35

38

40

40

42

47

49



Women do not face the same risks towards nutrition. Variables influencing nutrition were socio-economic, migration, employment and household factors. These factors were associated with higher level of poor nutrition among women. This knowledge could be used for better targeting women at risk in future interventions.

Risk factors of poor nutrition for young women

Sociodemographic and migration

Living in a hostel

Younger age group

Being less educated

Migrating from Bago, Ayeyarwaddy and Rakhine

Migrating between July to November

Employment Working for less than 6 months

Working for less than 40 hours a week

Having received skill training

Absent in the last 7 days

Food security Not having enough food in the household in the last 12 months

Having food access restrictions at the household

Not consuming enough Vitamin A, protein or iron rich food consumed at the household

Housing Living less than half an hour away

Not having a kitchen or cooking where women sleep

Sharing toilets and having pit latrines

Risk factors for women’s nutrition Based on the Minimum Diet Diversity Score for Women - refer to technical notes for more details on this indicator



1. Improve the quality and hygiene of food sold by street food vendors near the factories: Promoting good hygiene and nutrition practices should be supported for all selected street food vendors as drinks and sweet snacks were widely sold and issues around hygiene were noted. Seasonal support to food availability around the factories should also be encouraged. Standards awards, and certifications could be used for consumers to evaluate risks. Formative research on worker preference and consumer willingness to pay (WTP) should be conducted to identify the decision mechanisms for food choices and assess how much premium workers are willing to pay for safe and healthy options. In addition, information on the street food vendors business models can be captured to identify how much ensuring safety would cost these. A code of practices for the management of street food practices can be developed in close consultation with actors and professionals in food and health related disciplines. Street vendors within factories can be enlisted with the support of the local authorities and trained in Good Hygiene and Nutrition Practices. Street vendors in the targeted areas can be monitored and certified as sellers of ‘safe and nutritious food’ with routine checks.

2. Provide space and time for the women to cook: Women lack the time and ability to cook where they live. Simple solutions such as providing community kitchens in hostels should be encouraged by factories.

3. Invest in and support the implementation of nutrition promotion: The drivers of women’s eating behavior were not explored in this research. As the food choices in the shops around the factory were quite broad, it is important to understand how women make choices, the constraints they face (e.g. lack of time, money, knowledge) and what women know about healthy eating. If lack of knowledge is evidenced, the intervention should focus on nutrition education. Training should be offered to factory canteen workers and, food stall owners and female factory workers on nutrition with tailoring on what to buy (for workers) and what to sell (for vendors) to maximise health and well being. Behaviour change communication messages should be linked to positive benefit related to each party. So for vendors it could include ideas on how to use health benefits as a marketing tool while for buyers it could be sold around increased energy/beauty etc. Special focus should be given to newly arrived migrants who are experiencing significant changes from rural lifestyles and being in periods of transition are potentially more open to adopting positive new habits.

Recommendations



4. Conduct a full nutrition assessment to further assess women’s deficiencies and conduct pilot case studies: Detailed nutritional assessment should be carried out to assess women’s macro and micro nutrient deficiency levels and the contribution of street food to their dietary intake. Factories are excellent entry points to ensure that women meet their minimum diet diversity as well as macro and micronutrients. The use of fortified staples (e.g. fortified rice is already produced and available in Myanmar) or snacks rich in vitamins could be tested in such a setting to provide data for cost benefit analysis for the factory management.

5. Implement anaemia prevention and treatment programmes (iron supplement and food fortification). Currently in Myanmar, iron supplementation is only provided to pregnant women and adolescent school girls. Daily iron supplementation is recommended as a public health intervention in menstruating adult women and adolescent girls, living in settings where anaemia is highly prevalent (≥40% anaemia prevalence), for the prevention of anaemia and iron deficiency (WHO 2016). Evidence from DHS and this survey demonstrate high levels of vulnerability to anaemia within these target populations.



Technical notes

• Anaemia: was assessed based on the self reported clin-ical signs of anaemia including feeling weak, dizzy and suffering of cold hands and feet.

• The Food Consumption Score (FCS): FCS describes the current status of the household food consumption. It is a composite indicator based on dietary diversity, food frequency and nutritional importance of different food groups consumed the seven days before the interview (WFP 2008). In Myanmar, households with a FCS less than 38.5 are considered to have an inadequate diet.

• Household with inadequate food consumption: percent-age of households with poor or borderline food con-sumption as measured by FCS.

• Household with low diet diversity: the proportion of house-holds consuming 3 or less food groups the 24 hours prior to the survey which can be demonstrative of a poor quali-ty of diet and a high risk of micronutrient deficiency.

• The Food Consumption Score – nutrition (FCS-N): FCS-N looks at how often a household ate foods rich in a certain nutrient; Protein, Vitamin A and Iron (hem iron) primarily

for their nutritional importance. The thesis of FCS-N is that although the nutrient, for example Vitamin A, can be ob-tained from many foods, the number of times a house-hold ate food particularly rich in this nutrient can be used to assess likely adequacy of that nutrient.

• The Women Diet Diversity Minimum (MDD-W): MDD-W is a dichotomous indicator defined as the proportion of women 15–49 years of age who consumed food items from at least five out of ten defined food groups the pre-vious day or night (FAO and FHI 360 2016).

• The Household Food Insecurity Access Scale (HFIAS): The indicator is composed of a set of nine questions used and tested in several countries and aim to distinguish food insecure from food secure households. HFIAS can be used to assess the access component of food insecurity and the prevalence of household food insecurity (Coates et al. 2007).

• The Household Food Insecurity Access Prevalence (HFI-AP): The HFIAP indicator categorizes households into four levels of household food insecurity (access); food secure, and mild, moderately and severely food insecure.

References

FAO and FHI 360. 2016. Minimum Dietary Diversity for Women: A Guide for Measurement. Rome: FAO.

Coates, Jennifer, Anne Swindale and Paula Bilinsky. 2007. Household Food Insecurity Access Scale (HFIAS)

for Measurement of Household Food Access: Indicator Guide (v. 3). Washington, D.C.: FHI 360/FANTA.

WFP 2008. Food consumption analysis Calculation and use of the food consumption score in food

security analysis.

WFP 2015. Food Consumption Score Nutritional Quality Analysis (FCS-N)

Ministry of Health and Sports (MoHS) and ICF (2017) Myanmar Demographic and Health Survey 2015-16.

Nay Pyi Taw, Myanmar, and Rockville, Maryland USA: Ministry of Health and Sports and ICF.

ILO (2015) Myanmar labour force, child labour and school to work transition survey 2015.

Save the Children (2013). Cost of Diet Assessment in Hlaingthayar Township, Yangon. Unpublished.


Exploring food security and nutrition among young women in the

garment sectorBy Dr Lwin Mar Hlaing, Dr Kaday and Dr Sophie Goudet

exploring food security and nutrition among young women in

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