The readymade garment (RMG) industry is one of Bangladesh’s most important industries and contributes 81% of total export earnings and more than 14% of the GDP (2016–2017) [1
]. The sector directly employs approximately 3 million women [1
]. Although this industry has contributed to the growth of the economy and foreign earnings, it faces many limitations with respect to the low wage rate, insecure employment conditions, as well as the lack of safety and respect for female workers’ rights. Due to a low minimum wage, garment workers cannot afford adequate and appropriate food as well as clothing, housing, transportation cost, and medical expenditures [2
]. A recent study demonstrated that 77–80% of female Bangladeshi RMG workers are anemic [3
]. Anemia is associated with a significant productivity loss in terms of GDP [4
], increased maternal and perinatal mortality, and contributes to global mortality [5
]. Anemia is primarily caused by iron deficiency but also by other micronutrient deficiencies such as vitamins A, B2, folate, B12, and minerals like selenium, and copper [6
], and as well as several other non-nutritional causes [7
]. In Southeast Asia, it has been estimated that iron deficiency anemia is the cause of 26% of all anemia in women of reproductive age [8
]. However, there is a scarcity of evidence on the etiology of anemia and their relative proportion to the causes of anemia.
The inclusion of micronutrient-rich foods in the daily diet, such as red meat, green leafy vegetables and some nuts/seeds, is often not affordable for populations living under conditions of poverty in countries like Bangladesh, but may be addressed at the workplace if meals are provided for workers. In this context, food fortification could also be a cost-effective contribution to food-based approaches for preventing anemia by increasing the intake of iron and other micronutrients, a lack of which can cause anemia. The fortification of staple foods is advantageous because it does not require the population to change their dietary habits and allows fortification with multiple micronutrients since deficiencies often occur concurrently [9
]. Studies from Latin America, Africa, and India showed that rice fortification is safe and effective in improving micronutrient status, with the impact commensurate with the micronutrient content of the fortified rice, but as much as 53–80% [10
]. In rice-consuming countries like Bangladesh, multiple micronutrients fortified rice could be a promising strategy to address micronutrient deficiencies and thus reduce anemia. The workplace where RMG workers spend most of their waking hours could be an important entry point to address this substantial burden of anemia. The primary means of addressing anemia in this population of female garment workers in the short term will be through dietary modifications and rice fortification, complemented by iron/folate supplements (IFA). The benefits would be further if behavior change communication (BCC) messages are combined. BCC not only improves women’s dietary practices [14
] but also improves the compliance in IFA intake [15
], which further helps to reduce the risk of anemia [16
]. The non-nutritional causes of anemia, i.e., poor hygiene leading to infection, inflammation due to multiple causes including malaria, helminths, and chronic infections like tuberculosis [17
] could also potentially be addressed through BCC.
In this study, a workplace nutrition program was implemented in four RMG factories in Bangladesh to reduce anemia of female workers. The workplace program included a package of interventions which included nutritionally-improved lunches and weekly IFA supplements OR twice weekly iron supplements, as well as BCC (modules on nutrition including balanced diets/dietary diversity, iron/folate-rich foods, infant and young child nutrition (IYCN), anemia prevention, hand-washing with soap and dietary diversity), over a period of 10 months. The guidelines for nutritionally improved lunches available in factory canteens included: green leafy vegetables, lentils, fortified rice, fortified oil, and iodized salt every day and flesh foods at least three times a week. Regular lunches included non-fortified rice, lentils and one portion of vegetable daily and meat or fish or egg three times weekly, cooked with fortified oil and iodized salt. In these factories, IFA was provided once weekly, due to the additional iron supplied through fortified rice.
The evaluation of the effectiveness of such a nutritional intervention package is essential before scaling up. Hence, the current study aimed to evaluate the use of a different combination of packages to reduce anemia among female garment workers in these selected garment factories in Bangladesh. The results of this evaluation would help to inform government policymakers, donors, factory owners, and female garment workers about the benefits of the nutrition intervention and to advocate for the inclusion of appropriate nutrition interventions packages in the workplace in garment factories of Bangladesh.
To the best of our knowledge, this is the first nutrition intervention study in Bangladesh conducted among female RMG workers, which showed the effectiveness of a combination of interventions to reduce anemia. In our study, anemia prevalence in female RMG workers was reduced by 32 percentage points through the provision of a workplace nutrition program that included a nutritionally enhanced lunch through dietary diversification which involved micronutrient-fortified rice along with weekly iron-folic acid supplements and an enhanced health and nutrition behavior change approach. In another workplace nutrition program that included twice-weekly IFA and an enhanced BCC, anemia prevalence was reduced by 12%. In the control group, where just a basic BCC approach was included in the workplace program, we saw 6% increases in anemia. It was obvious that anemia reduces as Hb concentration increases. We also found a significant increase in Hb concentration in both intervention groups, with the highest reduction of 1gm/dL among nutritionally enhanced lunch meal group. A recent Bangladeshi study also found beneficial effects of fortified rice in anemia and Hb reduction [26
], but the rate of anemia reduction and an increase in Hb concentration was much lower.
We examine what we know about the evidence for the interventions included in the package to understand what components may have driven the reduction in anemia. First, we see a mild reduction even in the ‘control’ groups were some BCC was still provided. A systematic review of 201 trials indicated that the prevalence of anemia can be reduced by 46% when fortified foods are given an over a period of 6–11 months because the hematologic response should be evident after 6 months of the intervention [27
]. Our study findings also suggest that at least 10 months of intervention can reduce anemia significantly; since the prevalence of anemia is likely elevated in Bangladeshi female RMG population due to their poor dietary quality and pre-existing multiple nutrient deficiencies. A recent study in Ghana shows that micronutrient-fortified rice can be a significant source of dietary bioavailable iron [28
]. Both lunch meal intervention and non-lunch intervention packages contain moderate bioavailable dosages of iron (Table S4
) but the bioavailable iron content was relatively higher among the fortified lunch meal package; due to the presence of iron in rice and iron in IFA. This also helped us to understand that despite low adherence to IFA, the anemia reduction and increase in hemoglobin concentration was significantly higher in the fortified lunch package-receiving participants compared to controls. These findings suggest that there might be the presence of iron deficiency in this population for which the intervention rich in iron worked well in anemia reduction. As we did not test iron levels in blood, the possibilities of iron deficiency anemia in this population could not be ruled out. In our study, the iron supplementation doses were within the recommended level and we did not find any health adverse outcome during the study period except for the common side effects. However, high iron levels have increased the risk of mortality and decline in cognition levels in Chinese adults [29
]. Hence, we needed to be cautious about supplementing high doses of iron at the population level over the long-term, especially when the etiology of anemia is unknown.
The World Health Organization recommends providing intermittent doses of IFA (once or twice weekly) rather than daily doses as an effective and safer alternative to daily iron supplementation for preventing and reducing anemia at the population level, especially in areas where this condition is highly prevalent [20
]. Therefore, the current study also provided intermittent doses of iron-folic acid (IFA) supplementation once or twice weekly to female RMG workers. A systematic review indicated that intermittent dosing provided to menstruating women can reduce the prevalence of anemia by 27% compared to a control, regardless of dose and frequency (i.e., 1–3 times per week), and duration of the study [31
]. Our study findings also support this fact that intermittent dosing is more practical and feasible to maintain over the long term in a factory setting.
The adherence to IFA was lower in the weekly (37%) than the twice-weekly (100%) group. Several other studies have demonstrated the impact of IFA supplementation on the reduction in the severity of anemia among non-pregnant women [31
], pregnant women [34
] and adolescent girls [36
]. In our study, the severity of anemia significantly reduced in both lunch and non-lunch intervention factories that provide intermittent IFA along with BCC. Although, the effect of IFA with BCC on anemia reduction in our study is comparatively low, only 15 percentage points compared to the 32% reduction with IFA plus an enhanced lunch meal. This might be due to the low adherence to once weekly IFA, as most of the workers were not aware of the health benefits of IFA. They had a lack of knowledge about anemia, IFA tablet and the misconception about the side effects of the IFA tablet. In addition, BCC counseling was also irregular and short, which may have further reduced the effectiveness of IFA and BCC intervention. Even with the irregular BCC, the workers’ knowledge of nutritious food increased significantly in all four factories. In addition, the workers in three factories were more likely to report using sanitary napkins post-intervention, as was previously shown with a similar BCC program [38
]. This indicates a need for greater support for the BCC program to become effective and sustainable. In a discussion with the factory higher management, the reason for not supporting the program becomes clearer. According to the management, the BCC sessions made the workers more concerned about their rights and as a result, the factory had more job turnover than ever, and it caused more harm than good to the factory benefits. We also understood in some factories that workers were not keen on the BCC because it was during their productivity time and so they were feeling constrained. Thus, BCC should be provided outside factory hours but still hours paid by management. On the contrary, empirical evidence shows that industry-based training has resulted in the most favorable outcomes in terms of productivity, worker turnover and absenteeism reduction [39
]. Thus, building greater sensitivity and capacity among factory management by displaying the business benefit of BCC might help to improve the situation [40
]. Estimates showed that Bangladesh loses up to 8% of its GDP due to anemia [3
], which could be reversed by eliminating anemia through combined packages, including BCC.
A recent Bangladeshi survey estimated that roughly 5% percent of anemia is caused by iron deficiency [41
], although the exact amount in this population is not known. Other micronutrient deficiencies might prevail in this population, which explains the relatively lower impact of IFA on anemia reduction in our study. This finding also indicates that the significant anemia reduction might be largely due to the multi-nutrient enhanced lunch meal (21 percentage points). In addition, the workers were very satisfied with the quality, quantity, and taste of the enhanced lunch meal, which ensures the high adherence of lunch meal among the workers. The lunch meal not only reduced anemia but also was associated with an increase in the workers’ capacity of working for more hours and reduced reports of common co-morbidities like the common cold, urinary tract infection and joint pain significantly. The overall sickness absenteeism reduced in both lunch intervention and control factory, although the days of sickness absenteeism increased by one day from baseline. The IDIs revealed that the management at lunch meal factories easily permits their workers to take leave during sickness and did not deduct salary or benefits for sick leave if a proper reason was provided. This explains the relative increase in leave days due to sickness. Nevertheless, the good side was that the sick leave allowed the workers proper and rapid recovery from illness. We found a significant decrease in mean hemoglobin level and increase in anemia percentages among control factory workers from baseline. From IDIs we also identified a lack of support during sickness and family emergency and even salary cut during unauthorized leave in control factories. This might have caused long-term psychological stress and the increase in anemia from baseline [42
]. The enhanced BCC in lunch meal workers might have helped workers to practice appropriately during their home stay, which might have stopped the continuous progression of anemia for intervention factory, which did not happen for the control group. There is clear-cut evidence that providing sick leave can reduce turnover, increase productivity, and reduce the spread of contamination in the workplace [44
]. In this way, the lunch meal might have improved the work performances [45
]. This could be a significant finding for this sector as improved work performance may have improved their income through fewer unpaid sick days, and possibly in increased factory productivity. Literature suggests that, eliminating anemia results in a 5–17% increase in adult productivity, which adds up to 3% of GDP in Asian countries [4
]. Thus, an investment in nutrition in order to reduce anemia can potentially reverse productivity losses and could lead to associated benefits e.g., employee retention, reduced cost of training, reduced absenteeism, and improved employee motivation.
Strength and Limitation
This is the first evaluation study, which demonstrated a reduction of anemia in a population (RMG workers) that has the largest contribution to the country’s economy, but has yet never been targeted for any program or intervention. Several other studies have proven the efficacy and effectiveness of the intervention components (multiple micronutrients fortified rice, IFA, and BCC) separately [11
]. However, this study proved the effectiveness of the combination of intervention, especially in factory settings. We also checked for the possibility of confounding, i.e., if something external happened to the intervention factories and their communities to decrease anemia, e.g., presence of community screening program, presence of another program/intervention, IFA or any type of vitamin/supplements intake by the participants outside of the factory. However, there was no such program in the community at the time of this current study. This makes us more confident about the positive effects of workplace nutrition programs on anemia reduction. The qualitative approach also helped us to understand the context, feasibility, duration, and sustainability of the intervention in factory settings and further scale-up of the intervention. The mixed method design of this study further allowed us to triangulate the study findings and to understand the different perspectives of the intervention and the resulting outcome. This project had some limitations, e.g., (a) intervention duration was only 8–10 months; (b) interventions were not systematically tracked, particularly the IFA distribution; (c) compliance of IFA was low; (d) factory non-compliance (delay in providing information of workers, interfering in scheduling and during conduction of interview time); (e) lack of intervention randomization among pilot factories might not reflect the true effect of intervention; (f) about 40% of workers were lost to follow-up from baseline, (g) replacements of participants were done only based on age category and intervention duration, and (h) possibilities of iron deficiency anemia could not be ruled out due to lack of iron level testing in blood, which could have created a spurious effect on the findings. Hence, the findings needed to be interpreted cautiously. Due to the lack of a true control group, this study could not confirm the specific effect of any single intervention (i.e., without the inclusion of a BCC). What is also not clear is whether there was any additional benefit to including weekly IFA to the intervention incorporating fortified rice. Finding comparison groups in private sector settings is very difficult, and the factories who were willing to serve as counterfactuals were not likely representative of the average garment factory. In addition, baseline data indicate the anemia prevalence in these comparison factories was substantially lower than in the intervention factories. The large baseline difference in anemia status among lunch meal groups might have had an effect on overall study impact. The impact of intervention might have been different if the comparison group also had a higher prevalence of anemia at baseline as like lunch meal intervention group. However, we have adjusted these factors in our model. The study team could not measure the food intake and changes in factory productivity as the data were collected by another organization and not available to study investigators. We also could not rule out the other causes of anemia due to hemoglobinopathies, which is not rare in our country context [47
Anemia among non-pregnant female RMG factory workers can effectively be reduced by providing a combination of interventions over a significant period. Anemia reduced more significantly when the factory provided a freshly prepared, nutritionally enhanced lunch with fortified rice, increased diversity, and combined this with a weekly IFA tablet. Among non-lunch factories, IFA was able to reduce anemia significantly, but the rate of reduction was not as high as in lunch meal factories. In order to achieve the goal of a substantial reduction in the prevalence of anemia, a multidisciplinary approach is essential, with the active collaboration of all sectors involved, including government, donor agencies, local academic institutions, non-governmental organizations, and local communities. Therefore, government, policymakers and readymade garment factory owners should take initiative to implement and scale up this combined program to all garment factories in Bangladesh in order to successfully reduce and prevent anemia.