Background
Study setting
Methods
Study design
Target population | Method | Purpose | Planned sample | Actual sample | |
---|---|---|---|---|---|
Phase 1: understanding perceptions and demand | Households with a child under-5 | Questionnaire | To assess demand for centre-based child-care and current child-care practices | 200 households | 222 households |
Community leaders | Qualitative Semi-Structured Interviews (SSIs) | To understand perceptions of centre-based child-care | 5 SSIs | 5 | |
Mothers, fathers and guardians | Qualitative SSIs | To understand perceptions of and demand for centre-based child-care | 8 SSIs with those wanting to, 8 SSIs with those unwilling to use child-care centres | With those wanting to use child-care centres: 9 SSIs with mothers, 3 SSIs with fathers 2 SSIs with grandmothers With those unwilling to use child-care centres: 2 SSIs with fathers. Unable to recruit mothers, guardians unwilling to use centre-based care. | |
Policy-makers and ECD experts | Qualitative SSIs | To understand the context of ECD and centre-based care in Bangladesh | 5 SSIs | 5 | |
Phase 2: understanding implementation and feasibility | Mothers, fathers and guardians | Co-design focus groups (FGs) | To gain feedback on the planned model and inform the detailed specification | 2 FGs: 1 with slum and 1 with non-slum parents/ guardians. | 1 co-design FG of 8 mothers from slum households, willing to use a child-care. Unable to recruit FG of non-slum households. |
Users, non-users and centre staff | Qualitative SSIs Centre users’ meetings Monthly enrolment data | To understand experiences of using the child-care centre and to adapt the model to meet the needs of low-income families | Users, non-users and staff of the centre | 3 users’ meetings 10-months of enrolment data SSIs: 2 staff, 5 mothers still using centre, 3 mothers no-longer using the centre, 3 non-users who despite initial interest did not take up a place. | |
Households survey participants | Follow-up questionnaire 6 months after phase 1 | To identify the proportion of respondents traceable at 6 months | 222 households | 159 households traced |
Phase 1 understanding perceptions and demand for centre-based child-care
Household survey
Qualitative methods
Phase 2: understanding implementation and feasibility
Co-design and implementation of centre-based care
Follow-up of survey respondents
Data analysis
Quantitative
Qualitative
Integration of the quantitative and qualitative elements
Results
Participant characteristics
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 |
Perceptions: child benefits
“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)
“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)
“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)
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.
(Co-design focus group discussion)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.
“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).
“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).
“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)
Perceptions: social capital and trust in an urban environment
“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)
“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)
“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)
“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)
“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)
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 |
Perceptions: family first
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.“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)
Demand: work and childcare
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 |
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:“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).
Such strategies were clearly challenging and could lead to job-loss, as one woman who used our child-care centre, reflected:“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)
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:“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)
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.“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)
Feasibility: fees, food, hours and engagement
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 S4.“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)