1 Introduction

The onset of COVID-19 bought the entire world to a standstill and had a major impact on social and economic sectors, both globally and in India. The sudden lockdown led to a chain of events, including loss of employment and panicked hoarding of essential items. The interruption in the supply chain meant that an acute shortage of food was seen throughout the country, with those in the lower-income group being affected the most. The data that came out by the end of 2020 reflected some grim realities on how COVID-19 impacted hunger and triggered food insecurity around the world. The State of Food Security and Nutrition in the World report released by the Food and Agriculture Organisation of the United Nations revealed that in 2020, around 720 to 811 million people across the globe and 418 million in Asia alone were affected by hunger [1]. This was majorly fuelled by the pandemic and reports predicted that the effects of this year would ultimately affect our aim to achieve the Sustainable Developmental Goals (specifically SDG 2) by 2030.

FAO defines food insecurity as the state in which a person lacks regular access to enough safe and nutritious food for normal growth, development, and an active and healthy lifestyle [2] Dietary Diversity, on the other hand, is defined as the number of foods consumed across food groups over a period. This comes from the assumption that increasing the variety of food groups in your diet can help increase the essential nutrient intake and promote good health [3] Access to adequate food and nutritious food was severely affected across the country during COVID-19, and women handloom workers in Kerala were disproportionately affected by this as well [4].

One of the largest unorganised sectors in the country, handloom work is a tedious procedure that has truly withstood the test of time. Handloom work has a long history and the major centres of the occupation in the state today include the towns of Balaramapuram, Chendamangalam, Kuthampully and Kasaragod district in Kerala. According to the All-India Handloom census conducted by the Ministry of Textiles in 2019–20, handloom work employs around 35 lakh workers each year, with 2/3rd of the workers being women [5]. Loss of their only source of income due to slow business meant that most handloom workers could not afford necessities, and had to resort to other menial tasks to earn a living. The industry was severely in 2018, 2019 and 2020 by heavy floods, and COVID-19 struck while they were still recovering from the losses [6].

As the country entered a post-pandemic phase, not much had improved for the handloom workers. Food assistance from the Government of India in the form on the Pradhan Mantri Garib Kalyan Yojana (PMGKY), where 5 kg of rice or wheat and 1 kg of pulses would be provided free of cost through the fair price shops was made available [7], however, majority of the workers were out of job due to non-availability of yarn or poor demand, depriving them of a consistent income. One of the biggest sources of income for handloom workers in Kerala were school uniform materials, the production of which was halted because of the shift of classes to an online mode during the pandemic [8]. This led to both food insecurity and poor dietary diversity in the community, especially amongst the female handloom workers. Considering the uncertainty prevalent in the community, the present study aimed to measure the patterns of food security and dietary diversity amongst female handloom workers in Kerala.

2 Materials and methods

This study was carried out after obtaining approval from the Institutional Ethics Committee of Symbiosis International (Deemed University), Pune [Proposal No. SIU/IEC/388].The informed consent form in Malayalam was read out to the respondents before the commencement of the study. Respondents were briefed about confidentiality of the data, voluntary participation, and their right to withdraw from the study at any point of time.

2.1 Study setting

This community based cross sectional study was conducted in June 2022 among female handloom workers in the Ernakulam district of Kerala, India, where co-operative societies are spread across towns including Cherai, Vypin and Mulanthuruthy. While handloom work can be carried out at the household level, majority of the workers in Kerala work out of cooperative societies in their localities, to minimize operational costs. For this reason, data was solely collected from workers operating out of these societies.

2.2 Sampling

Data was collected from 140 female handloom workers from 9 co-operative societies across Ernakulam district, Kerala, using the purposive sampling method. Female handloom workers (Those who operate the looms in the cooperative society), aged between 30 and 70 years, who were willing to participate were recruited for the study.

2.3 Data collection and variables

After explaining the purpose of the study and obtaining written informed consent, demographic data including name, registration number of the handloom worker, co-morbidities, number of family members, their monthly salary, whether they have a ration card and whether they received ration under any government schemes were collected from the respondents. Anthropometric data consisting of weight and height was also collected during the study using a calibrated weighing scale and portable stadiometer respectively. The Body Mass Index (BMI) classified according to standards proposed by the World Health Organisation (WHO) have been used in the study [9]. Data regarding the food security and dietary diversity status of female handloom workers was collected using the validated Household Food Insecurity Access Scale and the Individual Dietary Diversity Scale respectively, which are elaborated further in the text. A day prior to data collection, respondents were asked to note down all their meals, beverages, and snacks for the day to reduce recall bias.

2.4 Food security assessment

Food insecurity amongst female handloom workers was assessed using the Household Food Insecurity Access Scale (HFIAS), which provides a simple and user-friendly approach for measuring the impacts of development food aid programs on the access component of household food insecurity. HFIAS, developed by the FANTA (Food and Nutrition Technical Assistance) Project, is a comprehensive 9-question scale used to estimate the prevalence of food security in low-resource settings. Unlike other tools, HFIAS evaluates different “domains” affecting food security, such as accessibility, affordability, and availability of food, making it one of the most extensive tools available to measure food insecurity [10]. The questionnaire was already translated into Malayalam and was pre-tested and validated in a previous study [11]. HFIAS consists of nine questions assessing three main domains of food insecurity, including anxiety and uncertainty about the household food supply, insufficient quality and insufficient food intake and its physical consequences. The questions further assess the number of times the respondent has experienced the situation (0 = never, 1 = rarely, 2 = sometimes, 3 = often). A score less than two meant that the person was food secure.

2.5 Dietary diversity assessment

Diet diversity amongst the population was measured using the Individual Dietary Diversity Score (IDDS), which assesses the number of food groups which were eaten by a specific target group the previous day or night [12]. Several studies have shown that Individual Dietary Diversity is an indicator for nutritional and micronutrient adequacy [13]. The IDDS was administered by collecting the 24-h recall from each of the respondents. A 24-h dietary recall is a structured interview conducted with the purpose of capturing detailed information about all foods and beverages consumed by the respondent for one whole day. Participants reported on meal content during the interview. Quantitative information on meals and food intakes were collected using standard measuring cups, spoons, and glass. They were probed for several details, such as the way in which tea was consumed (with or without milk and sugar), addition of spices, composition of curries (such as sambar and kurma, where vegetables added can vary from household to household) and number of meals consumed from outside to reduce recall bias. Based on the 24-h recall, items were divided into 12 food groups (Cereals, White tubers and roots, Vegetables, Fruits, Meat, Eggs, Fish and other seafood, Legumes, Nuts and seeds, Milk and milk products, Oils and fats, Sweets and Spices, condiments, and beverages), with a score of 1 for consumption of a food group and 0 for no consumption. A score below 8 meant that the person had a low dietary diversity.

2.6 Statistical analysis

The raw data was verified, entered into Excel and transferred to SPSS (Version 23) for statistical analysis. Descriptive statistics was used to calculate the mean, standard deviation, frequency, and percentage. Independent t-test and Chi-Square test were used to compare means and examine the relationship between continuous and categorical variables respectively. The level of significance was maintained at a p value < 0.05 with a confidence interval of 95% (CI).

3 Results

3.1 Demographic and socio-economic characteristics of participants

The demographic and socio-economic profile of the respondents is presented in Table 1. The mean age of the respondents was reported to be 53.69 ± 8.39. 70% of the respondents belonged to the age group 40–60 and a quarter percentage of them lived in families with more than 4 members. Majority of the respondents (91.4%) had co-morbidities with the most prevalent one being occupational hazards such as back and knee pains (45.7%). The monthly household salary and female handloom worker’s monthly salary were found to have median values of ₹ 5000 (IQR = 2500) and ₹ 2350 (IQR = 2000) respectively. The mean BMI of the group was found to be 24.35 kg/m2. An overwhelming majority of the respondents had ration cards (98.6%) and 77.9% of them received rations from the Fair Price Shop as part of the Pradhan Mantri Garib Kalyan Yojana (PMGKY). While conducting the unadjusted analysis, a statistically significant relationship was established between receiving PMGKY and food security status.

Table 1 Demographic characteristics
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3.2 Prevalence of food insecurity

Out of the 140 respondents, 96.4% of respondents were found to be food insecure. 33.57% reported anxiety and uncertainty regarding the household food supply, while 57.8% of people felt that they had to consume insufficient quality of food. 18.97% of people reportedly experienced insufficient food intake as well. Table 2 shows in detail the status of food security in the community, with 65% of participants reporting that they never had to worry about their households never having food.

Table 2 Participants’ responses to the nine items of household food insecurity access scale (HFIAS) (N = 140)
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3.3 Correlates of food security

Table 3 shows the relationship between Food security and availability of ration. While conducting the unadjusted analysis, a statistically significant relationship was established between receiving PMGKY and food security status. A significant relationship was also found between receiving PMGKY and not being able to eat the foods they preferred because of a lack of resources and having to eat a limited variety of foods due to a poor access to resources. Similarly, this study also showed statistically significant relationships between having a ration card, having to eat a smaller meal than they felt they needed because there was not enough food and having to go to sleep at night hungry because there was not enough food. The Chi-square test also showed a statistically significant relationship between the history of disease and limited variety of foods due to lack of resources (p = 0.003).

Table 3 Relationship between food insecurity and ration availability
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3.4 Prevalence of dietary diversity

Participants in the study reported consuming a variety of foods, with cereals (100%), other vegetables (94.3%), legumes and nuts (69.3%), vitamin A rich vegetables and tubers (60.7%) and fish and seafood being the most consumed food groups. Organ meats (2.9%), Flesh meats (7.9%) and vitamin A rich fruits (5%) were the least consumed food groups among the female handloom workers.

3.5 Correlates of dietary diversity

In unadjusted analyses, a statistical relationship was found between the food groups flesh meats, milk and milk products and food security status (Table 4). A statistically significant relationship was also seen between the following variables: History of Disease (such as diabetes and hypertension) and Vitamin A rich fruits consumption (p < 0.001), Household Size and other vegetables (p < 0.001), Household Size and Oils and Fats (p = 0.035), FHW’s monthly salary and milk and milk products consumption (p = 0.012), FHW’s monthly salary and Legumes, Nuts and Seeds (p = 0.016) and Monthly Household salary and Legumes, Nuts and Seeds (p = 0.046). While no significant relationship was observed between the BMI of the respondents and the other variables, a Kruskal–Wallis H test showed that there was a statistically significant difference between the BMI and FHW’s monthly salary (X2 = 11.23, p = 0.011).

Table 4 Food groups included in the dietary diversity score and the frequency by household food insecurity status
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4 Discussion

Post the onset of COVID-19 in Kerala, we have seen a decline in many social indicators, including food security and dietary diversity. While the results from this study show a substantially significant relationship between many of the demographic characteristics, food security status, dietary diversity score and the consumption of individual food groups, we were not able to establish a solid relationship between food security and dietary diversity.

While food security and dietary diversity did not have a statistically significant relationship which may be due to the homogeneity among the participants in terms of area of residence, profession, and income, and only 4% having food security status, several other variables, such as having a ration card and availing the PMGKY were found to be correlated to the consumption of several food groups and individual questions in the HFIAS questionnaire. These results highlight the strength of the current Public Distribution System, especially in Kerala, where PDS has played an instrumental role during the pandemic [14]. The Pradhan Mantri Garib Kalyan Anna Yojana (PMGKY), introduced in March 2020, was available to the holders of an Antyodaya Anna Yojana card. Under the scheme, beneficiaries will receive 5 kg of extra rations per month from the ration shops in addition to the monthly ration under the National Food Security Act 2013 [15]. Our results show a significant relationship between receiving these rations and household food security. The role of social protection schemes such as the PMGKY during and after COVID-19 has been monumental. World Bank states that nearly 74% of Indian households received food-based assistance through the PMGKY in 2020, and over 40% of poorer urban households have accessed food benefits [16]. During the interviews, participants too had emphasised on the importance of food assistance received through the PDS shops and how this had been helpful both pre and post COVID-19.

During the data collection process, the most frequently reported conditions include Occupational Hazards such as leg pain and back pain, hypertension, diabetes, thyroid, and asthma. Many of the respondents reported having more than one of the above diseases. This study was able to find a significant relationship between the history of disease and Vitamin A rich fruit consumption, however, the same cannot be said of the other food groups. Occupational hazards such as leg pain and back pain, common musculoskeletal issues seen amongst handloom workers, severely affect their health and quality of work [17, 18].

The median value of the monthly salary of female handloom workers and the household were found to be Rs 2350 (IQR = 2000) and Rs 5000 (IQR = 2500) respectively. Handloom work is an unorganised sector activity with inconsistent income. Because of recall irregularities and the fact that most people are reluctant to share information regarding their income, the chances of data being skewed is high, which is why the median value of income was considered. Several food groups such as milk and milk products and legumes, nuts and seeds were shown to have statistically significant relationships with both individual and household incomes [19, 20].

The study gives us an insight into the type of diet generally followed in Kerala. All the respondents unanimously reported having consumed cereals in their 24-h recall, with the most common cereal being rice. While there has been a decreasing trend in rice consumption in both urban and rural populations in the state, rice still accounts for 80% of all cereals consumed [21]. Retheesh P.K, et al., in their study, noted higher consumption of cereals among lower-income groups in Kerala and emphasized that diet diversification is directly proportional to the income of a person [22].

It is also important to note that while comparing the consumption of individual food groups amongst the female handloom workers, majority consumed fish, seafood, and other vegetables, which includes many of the locally grown vegetables. This is very reflective of the geographical location of the places where the study was carried out. Chendamangalam, Cherai and North Paravoor, the three main places where the study was carried out, are coastal towns with large fishing communities [23], hence making fish an affordable commodity.

While studies on food security and dietary diversity have rarely been conducted amongst the handloom workers’ community in India, similar studies on other populations outside India have been conducted. A study conducted on the impact of COVID-19 on food security and dietary diversity in Iranian households in 2020 showed a substantial decrease in dietary diversity during COVID-19 compared to before the start of the lockdown [24]. A similar study conducted in Nepal amongst lactating women showed that more than half of the mothers were food insecure and had poor dietary diversity [25].

There were a few limitations to this study as well. Research on handloom workers, while vast, mainly focuses on the type of work they do and its impact on the fashion industry. Several papers study the occupational hazards affecting the workers [26], but beyond that, the health of female handloom workers in India is rarely discussed or studied, a fact that had been brought up several times by the respondents during the study. The lack of research from an Indian perspective, especially in this population, meant that there was limited literature for reference. This could have affected the way questions were asked and prompts were given. Recall bias is another factor that must be considered in this case. While the chances of bias affecting the collection of 24-h recall are minimal because appropriate measures were taken to avoid it, the same cannot be said for administering of HFIAS questionnaire. The information for this questionnaire is collected based on consumption over the past month and therefore, the chances of bias cannot be completely rejected. The study was also missing several variables that would have given more statistically significant results, such as religion and caste, which play a huge role in the type of food consumed.

5 Conclusion

As the country moved into normalcy, the effects of COVID-19 were evident post the pandemic. An interrupted source of income meant that other factors, such as food security and dietary diversity were affected as well. It is important to acknowledge that quality nutrition, which plays an important role in the well-being of an individual, is poorly studied within the community of female handloom workers in Kerala. Further research into the nutritional knowledge, attitudes and practices amongst female handloom workers is recommended. This can also help in recognizing more efficient characteristics for comparison from an Indian context. Also, a multivariate analysis to identify the predictors of food insecurity among the handloom workers will help identify appropriate strategies to improve the status. Educating the community by conducting health camps and awareness sessions is also essential to sensitize them about health, nutrition, non-communicable diseases etc. The introduction of initiatives such as community kitchens and home gardens, which can substantially improve diet diversity is also necessary. Such practices can also help the community to be self-sufficient during any future emergencies like COVID-19. Investing in this research can help in shaping future policies and programs that can prove to be beneficial to the community.